
Class . lit 

Book 1 






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HUGHES' 
CO MP END OF PRACTICE 



SIXTH PHYSICIANS' EDITION. 



TO PHYSICIANS. 



The several essential qualities which a good Visit- 
ing List should possess are compactness, conveni- 
ence of arrangement, and strength to resist the 
unusual hard wear it receives. These qualities are 
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COMPEND 



PRACTICE OF MEDICINE 



BY 
/ 

DAN'L E. 'HUGHES, M.D., 

RESIDENT PHYSICIAN, PHILADELPHIA HOSPITAL; PHYSICIAN-IN-CHIEF, INSANI 
DEPARTMENT, PHILADELPHIA HOSPITAL J LATE DEMONSTRATOR OF 
CLINICAL MEDICINE IN THE JEFFERSON MEDICAL 
COLLEGE OF PHILADELPHIA, ETC., ETC. 



SIXTH PHYSICIANS' EDITION. 



THOROUGHLY REVISED AND ENLARGED. 



INCLUDING A SECTION ON MENTAL DISEASES AND A VERY COM- 
PLETE SECTION ON SKIN DISEASES. 



PHILADELPHIA : 

P. BLAKISTON'S SON & CO., 

IOI2 WALNUT STREET. 

1899. 







^ 



V- 



41799 



Copyright, 1899, by P. Blakiston's Son & Co. 



;» «ac 




SECOND COPY, 



WM. f^ 



FELL & CO., 

ELECTHOTYPEnS AND PRINTERS, 

1220-24 SANSOM STREET, 

HHILAUtLHHIA. 



TO 
HIS ESTEEMED FRIEND AND TEACHER, 

3-. /lib. 2>a Coeta, /lfo.2)., 

PROFESSOR OF THE PRACTICE OF MEDICINE IN THE 
JEFFERSON MEDICAL COLLEGE, 

THIS COMPEND 

IS RESPECTFULLY DEDICATED BY 

THE AUTHOR. 



PREFACE TO SIXTH EDITION. 



The continued demand for the Compend of Medicine has en- 
couraged the author to make its sixth edition the most complete 
of any similar book. It was never intended that the Compend 
should in any way replace the text-books upon the practice of 
medicine, but, on the contrary, it was written to be an aid to the 
medical student, at a time when practical demonstrations and ward 
classes were the exception in the college curriculum. The book 
has, however, somewhat outgrown the original plan, and having 
met with considerable favor from physicians, the author has en- 
deavored to make it more useful to the profession without changing 
the arrangement which has made it so popular with the student, 
always keeping in mind, however, that it is a compend and not a 
treatise on medicine. The addition of the section on Mental 
Diseases has been kindly received, and has justified the statement 
in the preface to the fifth edition that no medical student's education 
should be considered as completed without some knowledge of 
insanity, the increase of which is the alarm of the closing hours of 
the century. 

D. E. H. 



CONTENTS 



PAGE 

INTRODUCTION, 9 

FEVERS, 15 

General Treatment of Fevers, 16 

Continued Fevers, 17 

Periodical Fevers 39 

Eruptive Fevers, 51 

DISEASES OF THE MOUTH, 68 

DISEASES OF THE STOMACH, 76 

DISEASES OF THE INTESTINAL CANAL, 99 

INTESTINAL PARASITES, 134 

DISEASES OF THE PERITONEUM, 140 

DISEASES OF THE BILIARY PASSAGES, 147 

DISEASES OF THE LIVER, 151 

DISEASES OF THE KIDNEYS, 159 

DISEASES OF THE BLOOD, 195 

ACUTE GENERAL DISEASES, 209 

DISEASES OF THE RESPIRATORY SYSTEM, 244 

DISEASES OF THE NASAL PASSAGES, 263 

DISEASES OF THE PHARYNX, 269 

DISEASES OF THE LARYNX, 274 

DISEASES OF THE BRONCHIAL TUBES, 290 

DISEASES OF THE LUNGS 316 

DISEASES OF THE PLEURA, 346 

DISEASES OF THE CIRCULATORY SYSTEM, 352 

DISEASES OF THE NERVOUS SYSTEM, 401 

vii 



Vlll CONTENTS. 

PAGE 

DISEASES OF THE CEREBRAL MEMBRANES, 402 

DISEASES OF THE CEREBRUM, 409 

DISEASES OF THE SPINAL CORD, 449 

DISEASES OF THE NERVES, 475 

GENERAL OR NUTRITIONAL DISEASES, 4S4 

MENTAL DISEASES, 504 

DISEASES OF THE SKIN 531 

INDEX 611 



COMPEND 



OF THE 



PRACTICE OF MEDICINE 



INTRODUCTION. 

The Principles of Medicine constitute what may be termed 
Medical Science. 

The Practice of Medicine is the exercise of medical art, and 
embraces all that pertains to the knowledge of, prevention, and cure 
of the diseases which the physician is called upon to treat. 

Disease may be defined as any departure from the normal stand- 
ard of structure or function of an organ or tissue or in both com- 
bined : Organic disease, when associated with an organic change in 
the affected part ; Functional disease , when the abnormal phenomena 
are independent of any discoverable structural lesion. It is question- 
able whether alterations of function can occur without alteration in 
structure. 

The study of disease, whether organic or functional in character, 
is termed Pathology. 

Pathology is the science that treats of disease in all its aspects, 
and explains the origin, causes, clinical history, and nature of the 
various morbid conditions which may disturb the economy. 

The study of individual diseases constitutes Special Pathology, 
2 9 



10 PRACTICE OF MEDICINE. 

while the study of the morbid conditions common to a greater or less 
number of diseases constitutes General Pathology. 

Nomenclature, or the naming of diseases, is a subdivision of gen- 
eral pathology. The real value of nomenclature applied to disease is 
that the name chosen shall express the morbid condition involved, 
and, if possible, its location. 

If the morbid condition be an inflammation, the suffix His is added 
to the anatomical name of the part affected ; thus, if the disease be 
an inflammation of the peritoneum, it is termed peritonitis. 

If the morbid condition be catarrhal, such as a transudation or 
flux, the liquid escaping upon a mucous surface, the suffix rhoea is 
used ; thus, a catarrhal inflammation of the intestinal tract is termed 
diarrhosa and enterorrhcea. 

If the morbid condition be a flow of blood or a hemorrhage from a 
mucous, surface, the suffix rhagia is used ; thus, a hemorrhage from 
the small intestines is termed enterorrhagia. 

If the morbid condition be pain without inflammation, the suffix 
algia is used. The various forms of neuralgias are examples ; for 
instance, neuralgia of the stomach is termed gastralgia. 

If the morbid condition be in the blood, the suffix <xmia is used. 
Thus, Ana>?nia is impoverishment of the blood ; Ur&mia, the morbid 
accumulation of urea in the blood ; Septicaemia, putrid infection of 
the blood ; Pyaemia, purulent infection of the blood. 

If the morbid condition be in the urine, the ending uria is used. 
Albuminuria, when albumin in the urine ; Hematuria, when blood 
in the urine ; Oxaluria, when oxalates occur in the urine. 

If the morbid condition be a dropsical affection, the prefix hydro is 
added to the part affected. A dropsical accumulation in the perito- 
neum is termed hydro peritoneum. 

If the morbid condition be that of air in an unnatural part, the 
prefix pneumo to the name of the part is used, as in pneumothorax. 

If the morbid condition be an inflammation of the membrane 
investing the part inflamed, the prefix peri is used. Thus, an inflam- 
mation of the investing membrane of the kidney is termed perine- 
P J iritis. 

Inflammation of the connective tissue surrounding an organ is 
designated by the prefix para. Thus, parametritis for inflammation 
of the connective tissue about the womb. 

A termination in oma signifies a tumor, as \\\sarco?na ox carcinoma. 



INTRODUCTION. 11 

The suffix pathy is used to designate a morbid condition of a part, 
without indicating its particular character, an example being the use 
of the term encephalopathy. 

Morbid Anatomy, or pathological anatomy, a subdivision of 
pathology, is the study of the changes in the tissues and fluids of the 
body after death, appreciable either to the naked eye or with the aid 
of the microscope. 

Bacteriology is that division of science concerned with the study 
of bacteria, an important and developing etiological factor in the 
field of medicine and surgery. 

Histology is the study of the minute anatomy of the tissues and 
fluids of the body with the microscope and clinical chemistry. 

Hsematology, or the science of the blood, its nature, functions, 
and disorders. 

Pathogenesis is the study of the origin and development of 
pathological processes or disease. 

Lesions {Icedo, to hurt) are appreciable anatomical changes. 

Etiology is that subdivision of general pathology which treats 
of the causes of disease. The knowledge of the cause of any mor- 
bid action is of value in the prevention, management, and removal of 
disease. 

The Causes of disease may be divided into internal, external, 
ordinary, specific, primary, secondary , predisposing, and exciting. 

Examples of internal or intrinsic causes are those having their 
origin in the mind, such as prolonged mental application, intense or 
long-continued emotional excitement, long-continued mental depres- 
sion, and the possession of and concentration upon a predominant 
idea. Other examples are the accumulation of certain products in 
the blood, such as urea, uric acid, or lactic acid, or the absorption of 
ptomaines from the gastric or intestinal tract. 

External or extrinsic causes are such as infectious miasms, viruses, 
poisons, wounds, and injuries. 

An ordinary cause is one to which all are more or less exposed, 
such as atmospheric changes. 

Specific or special causes are those producing a distinct and specific 
disease, such as the bacillus tuberculosis, causing Tuberculosis; 
comma bacillus, Asiatic Cholera ; oscillaria malaria?, Malaria ; Loffler 
bacillus, Diphtheria. 

A contagious disease is one whose causative agent is a specific 



12 PRACTICE OF MEDICINE. 

poison that, introduced into the system of another, will give rise to 
the same disease. An infectious disease is also due to a special cause 
that under certain conditions is capable of unlimited increase or mul- 
tiplication. An infectious disease may or may not be contagious. 

An example of a primary cause is any external traumatic injury. 

A secondary cause is well seen in the secondary pericarditis result- 
ing from an accumulation of urea in the blood, the retention of the 
urea in the blood being due to a diseased kidney. 

A predisposition to disease is a special liability or susceptibility to 
its occurrence, and may be either inherited or acquired. 

Inherited or constitutional predisposition to certain diseases is also 
termed Diathesis ; an example is the offspring of phthisical parents, 
who are said to be of a. phthisical diathesis. 

Acquired predisposition is such as arises from — 
I. Habits: Strain upon the nervous system resulting in nervous 
diseases, or the changes resulting from alcoholic or other 
excesses. 

II. Age: Children are very liable to catarrhal disorders. Young 

adults, to fevers and perverted sexual disorders. 
Middle age, to heart, kidney, and digestive disorders, and 

cancer. 
Old age, to degeneration of the heart and vessels. 

III. Occupation: Miners, weavers, and cutlers, lung diseases; or 

painters and printers, to lead colic. 

IV. Sex : Women, emotional nervous diseases. 

Men, as more exposed, rheumatism and pneumonia. 
V. Race : Negro, phthisis and scrofula ; often exempt from mal- 
aria. 
Exciting causes are those giving rise to morbid conditions in indi- 
viduals already predisposed to certain diseases, but lacking the action 
which determines their occurrence, to wit : persons predisposed to 
acute rheumatism, on being exposed to certain atmospheric changes 
have an attack; fear has produced chorea; anger has caused 
jaundice ; worry has produced cardiac and mental diseases. 

The Clinical History of diseases includes all the symptoms and 
signs which may occur from the period of incubation until its final 
termination. 

Symptomatology is the study of the signs and symptoms of 
e or such alterations in the healthy functions giving evidence of 



INTRODUCTION. 13 

the existence of a diseased condition or perverted function. Symp- 
toms may be either objective or subjective : Objective, when evident 
to the senses of the observer, as redness, swelling, high temperature, 
or disorders of locomotion ; Subjective, when felt or known only by 
the patient, such as pain, numbness, vertigo, or nausea. 

Physical signs are, strictly speaking, objective symptoms, requir- 
ing for their elucidation special methods, such as inspection, mensura- 
tion, palpation, percussion, and auscultation. These methods are 
chiefly used in examinations of the chest and abdomen. 

Associated with the study of symptomatology should be considered 
the complications and sequelce of disease. 

Complications are certain conditions which may arise during the 
course of the original disease, but are not considered necessary 
accompaniments of the disease ; thus hemorrhage from the lungs or 
haemoptysis is a complication of tuberculosis ; intestinal hemorrhage, 
a frequent complication of typhoid fever. 

Sequelce (sequor, I follow) are the morbid phenomena left as a 
result of a disease ; thus, valvular disease of the heart often results 
from an attack of acute articular rheumatism. 

The Period of Incubation is that interval between the en- 
trance of a poison into the system and the manifestation of its 
symptoms. 

The Prodromes are the earliest recognizable symptoms ; as the 
rigors or chills during the invasion of fever, and the various aurse 
preceding an epileptic attack. 

An acute disease is one in which the invasion is sudden and rapid, 
and as a rule severe ; when the symptoms develop less rapidly and 
are less intense, the disease is said to be subacute ; when gradual 
or slow in development, duration, and intensity, the disease is said 
to be chronic. It must be borne in mind, however, that there 
may be disturbed action in every intermediate degree between these 
extremes. 

Pathognomonic is the term applied to such symptoms as belong 
to one particular disease, and are therefore characteristic of it, thus : 
the rusty sputum of pneumonia, or the eruption of variola. 

The Termination of a diseased action may occur in one of three 
ways, to wit : Cure, Secondary Processes, or in Death. 

Cure may occur by — 

Lysis, or slow return to health. Crisis, abrupt termination, usually 



14 PRACTICE OF MEDICINE. 

with a critical discharge. Metastasis, or changing from one location 
to another. 

Secondary Processes are those in which the diseased action is sub- 
stituted by a new morbid process, to wit : rheumatism followed by- 
endocarditis ; apoplexy by cerebral softening. 

By Death is meant a complete cessation of tissue change occurring 
by- 

Asthenia, or an ever-increasing debility, to wit : phthisis, cancer, 
Bright's disease. Ana>?nia, or insufficient quantity or quality of 
blood. Apncca, or non-aeration of blood, to wit : acute lung dis- 
eases, or croup. Coma, death beginning at the brain, to wit: urae- 
mia, narcotic poisoning, or cerebral hemorrhage. 

Diagnosis of disease, or the discrimination of diseases, implies a 
complete, exact, and comprehensive knowledge of the phenomena 
under consideration, as regards the origin, seat, extent, and nature of 
all its morbid condition. 

A direct diagnosis is made when the morbid condition is revealed 
by a combination of clinical phenomena, or some one or more pathog- 
nomonic symptoms. 

A differential diagnosis is the result when the diseases resembling 
each other are called to mind and eliminated from each other. 

A diagnosis by exclusion is by proving the absence of all diseases 
which might give rise to the symptoms observed, except one, the 
presence of which is not actually indicated by any positive symptoms. 

The X- (or Rontgen) Rays, now in its infancy in diagnosis, will in 
the near future revolutionize the study of diseases of internal organs 
and structures. 

Prognosis of disease is the ability or knowledge to foretell the 
most probable result of the condition present, and involves an amount 
of tact or knowledge only acquired by prolonged clinical experience. 

Treatment. The ultimate and most important object in the 
study of medicine, from a practical point of view, is to be able to cure, 
relieve, or prevent disease. This does not consist solely in the ad- 
ministration of drugs, but requires strict and faithful attention to diet, 
hygiene, and exercise. 

When the object is to prevent disease, such as small-pox by vacci- 
nation, it is called Prophylactic or Preventive treatment. 

When disease is to be broken up, although already begun, such as 
."boiling the < hill of malaria, it is called the Abortive treatment. 



FEVERS. 15 

When the disease is allowed to run its natural course without 
attempting its removal, but being constantly on the alert for obstacles 
to its successful issue, such as the generally adopted plan of treating 
continued fevers, it is called Expectant treatment. 

When the disease is incurable, and removal of marked suffering is 
the object, it is called Palliative treatment. 

When marked weakness and prostration are to be overcome, it is 
called Restorative treatment. 



FEVERS. 



Fever is a condition in which the temperature of the human body 
is raised above the normal limit, — 98. 2° F., — and there are present 
the phenomena of quickened circulation, marked tissue change, and 
disordered secretio?is. 

The primary cause of the fever phenomena is still a mooted ques- 
tion, and is either a disorder of the sympathetic nervous system giv- 
ing rise to disturbances of the vaso-motor filaments, or a derangement 
of the nervous centres located adjacent to the corpus striatum, which 
have been found, by experiment, to govern the processes of heat pro- 
duction, distribution, and dissipation, or a toxaemia, — viz. : ptomaines, 
uraemia, or other poisons, — or of a bacterial origin. 

Rise of temperature is the preeminent feature of all fevers, and can 
only be positively determined by the use of the clinical thermometer, 
The term feverishness is used when the temperature ranges from 99 to 
ioo° F. ; slight fever if ioo° or 101 ; moderate, 102 or 103 ; high 
if 104 or 105 ; and intense if it exceed the latter. The term hyper- 
pyrexia is used when the temperature shows a tendency to remain at 
106 F. and above. 

Quickened circulation is the rule in fevers, the frequency usually 
maintaining a fair ratio with the increase of the temperature. A rise 
of one degree Fahrenheit is usually attended with ah increase of 
eight to ten beats of the pulse per minute. 



10 PRACTICE OF MEDICINE. 

The following table gives a fair comparison between temperature 
and pulse : 



.V temperature 


of 


9S F. 


corresponds to 


a pulse 


of 60 


i c a 




99° F. 


" 




" 




" 70 


(< « 




ioo° F. 


" 




tt 




" 80 


« << 




ioi° F. 


it 




1 1 




" 90 






102 F. 
103 F. 


a 
ti 




a 




" 100 
" no 


it a 

( C ft 




104° F. 
IC5 F. 
106 F. 


n 




a 
a 




" 120 
« 130 

" 140 



The tissue waste is marked in proportion to the severity and dura- 
tion of the febrile phenomena, being slight or nil in febricula, and 
excessive in typhoid fever. 

The disordered secretions are manifested by the deficiency in the 
salivary, gastric, intestinal, and nephritic secretions, the tongue being 
furred, the mouth clammy, and there occurring anorexia, thirst, con- 
stipation, and scanty, high-colored, acid urine. 



GENERAL TREATMENT OF FEVERS. 

1. Reduce the temperature. The cold bath or cold pack will do 
this most decidedly, but entails much labor, and is not altogether free 
from danger, and so its use is advised only in proper cases. Cool 
sponging is of decided value. Quinines sulphas, in gr. xx (1.3 Gm.) 
doses, repeated, rarely fails. Antipyrin, gr. xx (1.3 Gm.), repeated, 
antifebrin, gr. x-xv (0.65-1.0 Gm.), repeated, and phenacetin, gr. v 
(0.32 Gm.), rep^c ?d once or twice, are also recommended, but their 
tendency to depression must be watched. 

2. Lessen the circulation. If the pulse be full, strong, and rapid, 
use aconitum or veratrum viride. If the circulation be weak, stimu- 
lants with digitalis, caffeina, and nitroglycerin are indicated. 

3. Attend to the secretions. Remove the waste of the tissues by 
diuretics, diaphoretics, and, if particularly indicated, laxatives. It is 
better for every fever that the skin should be moist, than that it should 
be harsh and dry. It is better that the urine should be abundant, 
than that it should be scanty and thick with tissue waste. Watch the 
Stools that you may judge whether the food, be it solid or liquid, is 



FEVERS. 17 

propeily digested. The free use of water is beneficial in promoting 
the various secretions. 

4. Nourish the patient. " Don't starve a fever." Administer milk, 
beef-tea, animal broths, peptonized and other light nutritious food, in 
small quantities, but at frequent intervals, watching that tympanites 
does not develop. 

Alcohol is only indicated in long-continued fevers or those of 
asthenic type. Check or discontinue alcohol when its odor is notice- 
able on the breath. 

5. Watch the nursing. Much of the success in the management 
of fever patients can be attributed to good, sensible nursing. Through 
it are secured the five important essentials of every sick-room ; to 
wit : cleanliness, cheerfulness, regularity, ventilation, and light. 



CONTINUED FEVERS. 

All continued fevers are characterized by a steady progress of the 
febrile movement, without either a too decided rise or fall in the tem- 
perature to modify the impression of a continuous action. 



SIMPLE CONTINUED FEVER. 

Synonyms. Irritative fever ; febricula ; ephemeral fever ; synocha. 

Definition. A continued fever, of short duration, mild in charac- 
ter, rarely fatal, but when death does occur, presenting no character- 
istic lesion. 

Causes. Fatigue, mental and physical ; exposure to the sun ; 
great heat or cold ; excesses in eating and drinking resulting in an 
attack of indigestion ; excitement and violent emotion. Most common 
in childhood. It is not a miasmatic fever, neither is it contagious. 

Symptoms. Onset sudden with an abrupt feeling of lassitude, 
followed by a decided chill or chilliness, a sudden and rapid rise of 
temperature, quick, tense pulse, headache, dry skin, great thirst, coated 
tongue, costive bowels, and scanty, high-colored urine. Cases due to 
errors in diet are accompanied by nausea and vomiting. Attacks 
occurring during childhood, due to excitement, fright, or the emotions, 
may be associated with convulsions. The temperature may within an 



18 PRACTICE OF MEDICINE. 

hour or two reach 103 F., or more, when slight delirium may occur. 
The affection has no constant or characteristic eruption. 

Duration. From twenty-four hours to six or seven days. 

Termination. Usually within a few hours, to a day or two, the 
temperature rapidly falls to the norm, an instance of crisis ; or it may 
continue for several days, gradually falling to the norm (lysis). Herpes 
about the lips and nostrils are often observed at the close of an attack. 
Convalescence is rapid. 

Diagnosis. Unless the fever can be attributed to some one of 
the causes mentioned, a doubt as to its character may exist for the 
first twenty-four hours, after which time it can hardly be mistaken for 
any other disease. 

The following is a familiar instance of this affection. A child, apparently 
in the best of health, at play, or, may be, at school, suddenly complains of 
nausea and may vomit, the skin becoming hot, dry, and flushed, or soon cov- 
ered with an erythematous rash ; the pulse is quick and tense, there is head- 
ache, pains in the limbs, and great fretfulness or nervousness. The axillary 
temperature may reach I02°-I04° F. The whole aspect is most alarming. 
A laxative is administered, the surface sponged with a tepid lotion, sleep 
follows, during which there may be free perspiration, and the following day 
the child is and continues perfectly well. 

Prognosis. Recovery, without sequelae, the rule. 

Treatment. Rest in bed. If evidences of gastro-intestinal dis- 
order be present, order a dozen or more powders containing hydrar- 
gyri chloridi mite, gr. l /e (001 Gm.); sodii bicarbon., gr. ij (0.13 Gm.), 
pulv. ipecac, gr. ^ (0.005 Gm.), one every two hours, and some 
hours after the last powder has been taken, an enema or a seidlitz 
powder. Much comfort follows sponging the surface with tepid or 
cold water and the use of saline diaphoretics and diuretics. If the 
pulse be very quick, add small doses of aconitum. Cases not 
associated with digestive disorder have the fever and nervous 
symptoms relieved by acetanilidum, gr. ij-v (0.13-0.32 Gm.), accord- 
ing to age, every two or three hours. Liquid diet is the most palatable. 
Cases in which the nervous symptoms or insomnia are prominent 
should have a few doses of potassii bromidum during the day, or a 
bedtime dose of trional, gr. v-xx (0.32-1.3 Gm.). During convales- 
< cm e tonic doses of quinines sulphas or tinctura nucis vomicce. 



FEVERS. 19 

INFLUENZA. 

Synonyms. La grippe ; grip ; contagious catarrh ; epidemic or 
catarrhal fever. 

Definition. An acute, specific, infectious fever, moderately con- 
tagious ; sporadic, epidemic, and pandemic ; associated with catarrhal 
inflammation of the respiratory tract, sometimes of the digestive, 
muscular pain, and always accompanied with disturbances of the 
nervous system and a debility out of all proportion to the intensity of 
the fever and the catarrhal processes and apt to be attended with 
serious complications and sequelae. 

The disease was almost unknown upon the appearance of the 
pandemic in the winter of 1889-90. 

Causes. A specific poison, the bacillus of Pfeiffer, which is unin- 
fluenced by soil, climate, season, or atmospheric changes. The mode 
of development of the remarkable outbreaks of influenza is not yet 
understood. One attack rather predisposes to another attack. 

Morbid Anatomy. There are no characteristic anatomical 
lesions. Any anatomical changes are those of the complications. 

Symptoms. The clinical history of this disease presents the 
greatest variations as regards intensity, from the most trifling indis- 
position in one, to an illness of the gravest kind, terminating in death, 
in another. 

The onset is, in the majority of cases, sudden, with a chill ox chilli- 
ness followed by fever, the temperature reaching 101 to 103 , a quick, 
compressible pulse, and severe shooting pains in the eyes and frontal 
sinuses and myalgic pains in the joints and muscles. The chill and 
fever are rapidly followed by chilliness along the spine, pain in the 
throat, hoarseness, deafness, coryza, sneezi?ig, injected, watery eyes, 
and a dry, irritative, laryngeal cough, sometimes becoming bronchial. 
Rarely there is severe and obstinate cough, the result of a bronchial 
spasm, with little or no secretion. The tongue is furred, there is 
anorexia, epigastric distress, nausea, occasionally vomiting, and often- 
times diarrhoea. In some instances the digestive symptoms are the 
most prominent, when dysentery may occur. Associated with either 
the respiratory or digestive form of attack may be marked disturb- 
ances of the cerebro-spinal functions, or these latter may be the most 
prominent symptoms present. 

The above symptoms are always associated with depression of 



20 PRACTICE OF MEDICINE. 

spirits, and a debility altogether out of proportion to the intensity of 
the fever and the catarrhal phenomena. Delirium is rare, but marked 
hebetude and cutaneous hyperesthesia are common. 

Duration. The fever declines in from four to seven days, when 
begins a protracted convalescence. Relapses frequently occur, and 
second, third, or even more numerous attacks in the same individual 
may be observed, the susceptibility of the system after an attack 
being remarkable. 

Complications. The most frequent are those associated with 
the respiratory organs. Severe bronchitis, associated in the feeble 
or aged with fever, typhoid delirium, and tendency to oedema of the 
lungs. Croupous and catarrhal pneumonia are frequent and fatal 
complications. Cerebro-spinal meningitis is also noted. 

Sequelse. A persistent headache ; neuralgia; neuritis; insomnia; 
neurasthenia or a confusional insanity ; depression of spirits often 
obstinate and needing treatment ; mania ; enlargement of lymphatic 
glands. The great increase in pulmonary phthisis since the pan- 
demic of 1889-90 is more than a coincidence. 

Diagnosis. Isolated cases maybe mistaken for a "bad cold." 
But when epidemic, the sudden onset, ?7iarked general catarrh, and 
decided prostration should prevent error. 

At the onset of an epidemic Dengue will be remembered. Cerebro- 
spinal Fever has many symptoms in common with the nervous form 
of influenza. 

Prognosis. Recovery is the rule when it occurs in the healthy 
and vigorous ; according to Pepper less than one-half of one percent, 
die. Grave when the very young, the very old, or those suffering from 
organic disease, such as Bright's disease, fatty heart, emphysema, or 
the tubercular diathesis, are attacked. 

Treatment. No specific. During the prevalence of the epi- 
demic influence exposure to cold should be avoided. Support the 
system and pursue a purely symptomatic method of medication. 
All measures, of whatever kind, which tend to depress the general 
nervous system, or the functional activity of the respiration, and 
particularly the heart, are to be avoided. Patients should be kept in 
bed until fever declines or longer. Keep the bowels soluble. If many 
individuals must come in contact with the patient, some isolation and 
disinfection of the nasal and bronchial secretions should be prac- 
tised. 



FEVERS. 21 

The catarrh, pains, and cough are at least ameliorated by the 
following : 

$. Phenacetin., gr. iij .2 Gm, 

Pulv. camphorae, gr. j .065 Gm. 

Caffeina citrata, gr. j .065 Gm. 

Every two or three hours, alternated with quinines sulphas, gr. ij (0.13 
Gm.). 

Excellent results follow the use of the following combination : 

rjc . Sodii benzoat. , .' 3 ij 8. Gm. 

Salol, gss 2. Gm. 

Phenacetin., gr. xl 2.6 Gm. 

Strychninse sulph. , gr. \ .012 Gm. M. 

Ft. chart, vel capsul. No. xij. 

Sig. — One every three or four hours. 

Sodii benzoas, gr. x (0.65 Gm.) every four hours, is strongly recom- 
mended. 

During the last pandemic the disease was frequently aborted in 
those of vigorous health by a few ten- or fifteen-grain (0.65-1 Gm.) 
doses of antipyrin, although in those of feeble resisting power much 
harm resulted from the indiscriminate use of this drug. Dr. Roland 
G. Curtin warmly recommends salicinu7?i as coming " as near to being 
a specific as we can get with the drugs now in our possession." 
Quinines sulphas, in full doses at the very onset, often aborts the 
disease. 

I have seen excellent results in neuralgic cases from cinchonidina 
salicylas, gr. v (0.32 Gm.), every four hours. 

The frequent inhalation of tinctura benzoin. co?np., f^ss-j (2-4 
Cc.) in aqucE but., Oj (475 Cc), relieves the naso-pharyngeal and 
bronchial catarrh. 

If the bronchial symptoms become troublesome, use — 

R . Ammonii chlorid. , 
Tinct. hyoscyami, 
Syr. ipecac, . . 
Spts. frumenti, . 

Aquae chloroformi, f^iss 6. Cc. M. 

Every three or four hours diluted. 

The complication of pneumonia requires prompt stimulating treat- 
ment. Dr. Pepper recommends strychnin a sulphas in full doses as 



gr. x 


.65 Gm 


TT\,xv 


1. Cc. 


n\v 


.3 Cc. 


f ^ss 


2. Cc. 


fgiss 


6. Cc. 



22 PRACTICE OF MEDICINE. 

the most important remedy against this complication, and suggests 
the following combination as often valuable : 

& . Morphinse sulph., gr. j .065 Gm. 

Quininge sulph., . . gr.xxxv 2.3 Gm. 

Strychninse sulph., gr. ss .03 Gm. 

Acid. phos. dil., f^ iij 12. Cc. 

Glycerini, . . f^ v 20. Cc. 

Aquae, . q. s. ad f ^ iij 90. Cc. M. 

SlG. — A teaspoonful four to six times daily, in water. 

Dr. Bartholow recommends the early use of pilocarpine, gr. l /e (0.01 
Gm.), repeated until its mild physiological effects ensue, when it is sub- 
stituted by duboisine, gr. -g^o _ ^o- (0.00022-0.00032 Gm.), twice a day, 
and for the depression ferri iodidum, one of the official pills every 
four hours, and inhaling one or two drops of pyridine every few 
hours. 

During convalescence administer strychnines sulphas, gr. -fa 
(0.0013 Gm.) four times daily. 

Always have in mind that influenza is often the exciting cause 
of a phthisical development in those so predisposed. Insomnia is a 
symptom calling for prompt treatment. The anaemia and general 
weakness of convalescence calls for ferrum. 



TYPHOID FEVER. 

Synonyms. Enteric fever ; gastric fever ; nervous fever ; entero- 
mesenteric fever ; abdominal typhus ; autumnal fever. 

Definition. An acute, infectious febrile affection, due to a 
special poison ; characterized by insidious prodromes, epistaxis, 
dull headache followed by stupor and delirium, red tongue, becom- 
ing dry, brown, and cracked, abdominal tenderness, early diarrhoea 
and tympany, and a peculiar eruption upon the abdomen; rapid 
prostration and slow convalescence ; a constant lesion of Peyer's 
patches, the mesenteric glands, and enlargement of the spleen. 

Causes. Predisposing and exciting. 

The chief predisposing causes are Age and Season. It is claimed 
by Pepperthat a particular susceptibility exists in certain individuals 
and families to typhoid fever. 

The most frequent age is between fifteen and thirty years, and 



FEVERS. 23 

cases are rarely seen in those of forty-five years and over. I have 
seen well-marked cases with typical symptoms at eighteen months, 
and at five years of age. The autumn months show the most cases, 
and particularly following a hot and dry summer. 

The exciting cause is a special typhoid germ, the typhoid bacillus 
or bacillus of Eberth, which is found in the lesions and blood. 

The poison usually results from the decomposition of the typhoid 
stools and the sputum, although it has been claimed that the disease 
may be generated under certain undetermined circumstances, de 
novo, from ordinary filth and decomposition ; this view has less 
advocates each year. 

The contagiousness of typhoid fever is again advanced. 

The atmosphere is never impregnated with the fever germ. The 
poison gains its entrance into the system by means of infected water, 
milk, ice, meat, or other food. The germ is easily destroyed by 
thorough disinfection of the stools and sputum with heat, mercuric 
bichloride, or acidum carbolicum, but extreme cold will not destroy 
the typhoid germ. 

Pathological Anatomy. The specific anatomical lesions of 
typhoid fever are invariably present, and are so characteristic that 
an examination of the body after death will in any case make known 
the nature of the disease, even had the symptoms been unknown. 
These lesions consist in changes in the Peyerian patches and solitary 
glands, which may be divided into well-defined stages, as follows : 

First. Stage of Infiltration, or Swelling from infiltration and ex- 
cessive proliferation of their cellular elements ; the surrounding 
mucous membrane is also infiltrated with cells. The Peyer's patches 
are thickened, hardened, and elevated above the mucous membrane. 
The number of patches and glands involved is from three or four up 
to nearly the entire number. The above changes have been noted 
as early as the second day. 

Second. Stage of Necrosis, Softening, or Sloughing of the solitary 
and agminate glands. Not all the patches necessarily slough ; in a 
certain number of them the morbid changes are arrested before soft- 
ening. This stage constitutes the anatomical changes of the second 
and third week. 

Third. Stage of Ulceration following and depending directly upon 
the softening and sloughing, the sloughs gradually separating, begin- 
ning at the periphery of the swollen gland and finally, at about the 



24 PRACTICE OF MEDICINE. 

end of the third week, become detached, leaving ulcers of various 
sizes. 

Fourth. Stage of Cicatrization, or in rare cases Perforation. The 
ulcer gradually diminishes in size, the surface becoming covered with 
a delicate layer of granulations, which is soon transformed into con- 
nective tissue and covered with epithelium, the resulting scar being 
slightly depressed. The gland-structure is never regenerated. 

The Mesenteric glands become infiltrated, enlarged, and softened, 
but seldom ulcerate. In about one-third of the cases the large intes- 
tine is also involved. 

The Spleen also enlarges and softens, the increase being twice or 
three times its normal size, beginning in the middle of the first week, 
and reaching its height at the end of the second week. 

There are, besides, parenchymatous degenerations , or granular 
cha7iges in all the active organs and tissues of the body. 

Symptoms. Stage of Prodronies. — The onset is insidious, with 
a feeling of general malaise, vertigo, headache, particularly occipital 
pain, disordered digestion, disturbed sleep, epistaxis, depression, and 
muscular weakness, followed by a chill ox chilliness, the patient being 
unable to designate the day when the symptoms began. In rare 
instances the disease begins abruptly with a chill, followed by high 
fever ; this is particularly the case in malarial districts. 

The exact duration of these premonitory symptoms is not known, 
and may be said to vary from a few days to two or three weeks. 

First Week, dates from the onset of the fever, when are present in- 
creasing temperature, frequeiit pulse, headache, listlessness, the eyes 
closed as if asleep, coated tongue, nausea, diarrhcea (there may be 
constipation), the abdomen moderately distended and, upon pressure 
in the right iliac fossa, gurgling sounds and tenderness. Upon the 
seventh day a few reddish spots resembling flea bites appear upon the 
abdomen, chest, or back. 

Second Week. The foregoing symptoms are exaggerated ; fever is 
now continuous, with a frequent and compressible and dicrotic pulse, 
tympanitic, tender abdomen, gurgling in the right iliac fossa, nocturnal 
delirium, severe and constant headache, often stupor, a short cough 
with distinct bronchial rales on auscultation, irregular muscular con- 
tractions (subsultus iendinum), sordes upon the teeth and lips, the 
tongue losing its coating and becoming more or less dry, the diarrhaa 
continuing. During this stage deafness develops, often increasing 



FEVERS. 25 

until profound, and continuing into convalescence. Disturbances of 
vision are frequent in pronounced cases. The spleen increased in size. 

Third Week. Fever changes from continuous to remittent ; the 
evening exacerbations continue as high as the preceding week, the 
morning fall growing more decided each day, but all the other symp- 
toms remain about the same until near the end of the week, when a 
marked amelioration begins. 

In a fair proportion of cases all the symptoms grow worse toward 
the end of the second or during the third week. The prostration is 
extreme, the stupor so marked that it is hardly possible to rouse the 
patient, the tongue dry, hard, cracked, and covered with a brown 
crust, sordes collect on the gums, teeth, and cracked lips, the pulse is 
rapid and feeble, the respirations shallow and quickened, retention 
of urine, which contains albumin. The stools are often voided invol- 
untarily, and bed-sores develop, this condition terminating in death, 
or passing thus into the fourth week. 

Fourth Week. The fever decidedly remits ; almost normal in the 
morning, the pulse becoming less frequent and more full, the tongue 
gradually becoming clean, the abdomen lessens in size, the diarrhoea 
ceases, the patient passing into a slow convalescence, greatly emaci- 
ated, which convalescence may continue for several weeks. 

Analysis of Symptoms. The temperature record of typhoid 
fever is characteristic. The fever on the morning of the first day may 
be stated at 98.5 F., evening 100. 5 ; second morning 99. 5 , evening 
101.5 ; third morning 100. 5 , evening 102. 5 ; fourth morning 101.5 , 
evening 103. 5 ; fifth evening 104.5°. From that time until end of the 
second week the evening temperature ranges between 103° and 105°, 
the morning temperature being a degree or more lower. During the 
second or third week hyperpyrexia, or fever above 105° F., may 
develop and adds to the gravity of the attack. A high temperature 
during the third and fourth week is of grave import. Temperatures 
of io6°-io7° with recovery are reported, but they must be rare. 

Afebrile cases of typhoid fever are reported, all other symptoms 
with the prostration, but the step-like temperature, being present. 

Diarrhoea is the principal intestinal symptom ; if absent, the lesion 
may be slight. The stools are at first dark, but early in the second 
week they become fluid, offensive, ochre-yellow in color, resembling 
" peasoup," and may be streaked with blood. They number from 
three to fifteen during the twenty-four hours. 
3 



26 PRACTICE OF MEDICINE. 

Constipation occurs more frequently than is supposed. I have 
seen one hundred cases with constipation within the past ten years. 

The urine has the ordinary febrile characters. Retention is very 
common. Ehrlich describes a reaction which he believes is rarely 
met with save in typhoid fever. In examinations of the urine by 
Ehrlich's diazo-reaction in fifty cases of typhoid fever in the wards of 
the Philadelphia Hospital, the reaction was found in thirty-eight. It 
has also been found in a number of other conditions, particularly 
those having gastro-intestinal symptoms. 

Eruption is almost constant. Consists of from. Jive to twenty small, 
rose-colored spots on the abdomen, chest, or back, sometimes on the 
limbs, appearing in crops, lasting about five days, disappearing on 
pressure and at death. Returning with relapses. Eruption day 
from the sevetith to the ninth. 

Rarely spots of a delicate blue tint — the "taches bleuatres " of 
French authors — are observed. 

Nervous symptoms are, pronounced headache, early and severe, 
dullness of intellect soon following, passing into drowsiness and 
stupor, with great prostration. Deafness pronounced. Sight im- 
paired, and in grave cases double vision. Deliriuin low and mutter- 
ing, generally pleasant in character ; always present in severe cases. 
Coma vigil \s a grave symptom, the patient lying perfectly quiet with 
eyes open, taking no heed to his surroundings. 

Splenic enlargement is an almost constant clinical feature. A ver- 
tical dullness exceeding two ribs and an interspace signifies enlarge- 
ment. Palpation is a valuable aid for determining splenic enlarge- 
ment. 

Muscular symptoms are developed late in the second or early in 
the third week, and consist of irregular contractions, carphologia, or 
subsultus iendinum, and are the result of the great debility. The 
reverse of muscular contractions, to wit, lying perfectly motionless 
in bed, attempting no muscular effort of any kind, is a grave sign. 

Convalescence shows great debility and emaciation, extreme 
anaemia, and severe nervousness, often very protracted. It is during 
convalescence that irritability of the heart, profuse night-sweats, and 
insomnia occur, and in women loss of hair. 

Complications. Intestinal hemorrhage is the most frequent 
and at times the most critical of any of the complications of typhoid 
fever. The hemorrhage may occur any time between the fourteenth 



FEVERS. 27 

and twentieth day ; a sudden decline of the temperature to the norm 
or below frequently precedes the passage of blood by stool. The 
hemorrhage is due to the erosion of a vessel during the ulcerative 
stage. 

Perforation makes the case almost hopeless. Peritonitis without 
perforation adds to the gravity, but is not necessarily fatal. 

Lobar pneumonia, hypostatic congestion, and bronchitis are fre- 
quent occurrences. There are few cases that do not have slight 
bronchial cough from the onset. Albuminuria and acute nephritis 
may occur, as may phlegmasia dolens, the result of thrombosis of the 
femoral vein, usually the left. Bed-sores are frequent, resulting from 
the impaired nutrition, emaciation, and pressure over bony promi- 
nences, and the difficulty of keeping the patient clean. 

Ulceration of the tongue and mucous membrane of the cheek is 
sometimes seen. 

Sequelae. Paralysis, — either mono- or paraplegia, — due to an acute 
neuritis. Post-febrile insa?iiiy occurs more frequently after typhoid 
than any other febrile condition, save influenza. Acute Nephritis 
associated with cedema. Alopecia, complete or partial. Trans- 
verse markings of the nails. Tuberculosis may develop in those 
predisposed. 

These sequelae of typhoid fever are all the result of the impaired 
nutrition and great prostration. 

Relapses are common, Da Costa reporting five in one patient, 
and Wilson (J. C.) four in one of his cases. The symptoms all return 
abruptly ; the duration is half the time of the original attack ; occur 
at the end of the fourth or beginning of the fifth week. Not so. fatal 
as generally supposed. 

Abortive typhoid fever are cases of mild character, having many 
of the typical symptoms, running its course in about two weeks. The 
so-called walking cases are often of this character. 

Diagnosis. The Widal reaction or serum-test gives brilliant 
promise for the early and correct diagnosis of the disease. Widal 
and others showed that " if to a drop of blood-serum, or to a drop 
of water containing a solution of dried blood from a typhoid patient, 
a moderate number of typhoid bacilli were added, a peculiar reaction 
occurred," seen under the microscope as a loss of the natural motility 
and an agglutination of the bacilli — a clumping into masses. 

An error that is constantly being made is that of confounding 



28 PRACTICE OF MEDICINE. 

typhoid fever with the typhoid (depressing) symptoms or conditions 
developing during the course of many acute diseases. The absence 
of the characteristic diarrhoea, the peculiar eruption, and the typi- 
cal temperature record and enlarged spleen should prevent the 
error. 

Enteritis has intestinal derangement and an irregular fever course. 

Peritonitis, abdominal symptoms only, with constipation and rapid 
early prostration and collapse. 

Acute miliary tuberculosis is often mistaken for typhoid fever, an 
error difficult to prevent at times. The perfection of the Widal 
reaction and diazo- urine reaction may remove the doubtful points 
in the near future. 

Meningitis lacks the intestinal symptoms and fever record. 

The so-called typho-malarial or malario typhoid fever has many 
symptoms in common, but lacks the diarrhoea, eruption, and temper- 
ature record. 

Prognosis. A positive prognosis cannot be made. Favorable 
indications are constipation, or slight diarrhoea, low temperature, and 
moderate delirium. Unfavorable symptoms are obstinate and severe 
diarrhoea, early high temperature, cardiac exhaustion, marked ner- 
vous symptoms with coma vigil or stupor, albuminuria, and repeated 
intestinal hemorrhages. 

The prognosis is always more favorable in winter than in summer. 

When death occurs, it is usually during or about the third week, 
the result of exhaustion, cardiac failure, or some complication. 
Children under puberty usually recover. More women than men 
die, although less women have the disease. Pregnant women and 
fleshy people usually succumb. 

The mortality in typhoid fever in private practice is about one 
death in twenty ; in hospital practice it varies from one death in five 
to ten cases, although the cold bath treatment has greatly reduced 
the hospital mortality. 

Treatment. There is no specific treatment for typhoid fever. 
The indications are to sustain life and meet the urgent and danger- 
ous symptoms as they arise. 

Flint held that, as it was a self-limited disease, "if the patient can 
be kept alive after three, four, or more weeks, recovery will take' 
pla< e provided there be no serious complication. In a case of severe 
uncomplicated fever the patient is in a situation not unlike that of a 



FEVERS. 29 

person in danger of drowning not far from or perhaps very near the 
shore. If he drown, it is because his strength gives way before the 
shore is reached. As a person in this situation requires only to be 
buoyed up by some support, so the fever patient in a similar emer- 
gency may only need supporting measures to live." 

It is important to secure intelligent nursing, a quiet, airy sick- 
room with an average temperature of 65° F., and the most scrupu- 
lous cleaiiliness of patient, bedding, and utensils. The patient 
must go to bed from the moment of suspicion that typhoid fever is 
developing, and remain in bed until convalescence is well established. 

The stools and urine must be disinfected the moment voided, and 
quickly discharged into a sewer or buried. 

The diet should be nutritious and liquid at intervals of every two 
or three hours. Diluted milk is the best article, but broths, soups, 
liquid peptonoids, coffee, and cold milk and tea may be alternated. 
A word of caution, however, as to the quantity of food administered. 
The amount should be small, as the digestive capacity of the patient 
is greatly lessened by the febrile phenomena. Much harm results in 
typhoid fever from stuffing the patient. Watch stools for undigested 
milk. 

The tendency to bed-sores must be kept in mind. The use of finely 
powdered boric acid over irritated parts will often prevent their devel- 
opment, or if developed, are healed by constant applications of bov- 
inine on several layers of gauze. 

Attention should be given to the mouth, and the dryness and ten- 
dency to collections of sordes prevented by frequently washing with 
glycerine and water or weak boric solution. 

The following remedies have advocates, claiming that they modify 
the course of the disease : hydrargyrum, iodum, acidum carbolicum, 
mineral acids, argentum nilras, guaiacum, and ergola, but no one drug 
can claim specific action. 

The reduction of temperature is one of the most important indica- 
tions in the majority of cases of typhoid fever. There is now no 
doubt that the former views regarding the amount of fever a patient 
could stand for one or two weeks are responsible for the high mor- 
tality in this disease. A temperature of 103 to 105 for a dozen days 
is dangerous and should be combated. Among the measures that 
have been used with success in many instances is quinines sulphas, 
gr. xv-xx (1-1.3 Gm.), morning and night. A strong prejudice has 



30 PRACTICE OF MEDICINE. 

arisen against quinina within the last few years, nevertheless, I know 
I have seen great benefit from its use, and strongly recommend it. 
Cold sponging with water alone or alcohol and water is often of 
great value in mild cases, and when sponging it is essential to leave 
the surface very wet. The cold pack is a very powerful antipyretic 
and, in cases with temperature of 104 or 105 , in which the cold bath 
cannot be employed, can be made use of. The bed should be pro- 
tected by a rubber cloth, and the patient, with his clothing removed, 
should be wrapped in a sheet wrung out of cold water. The surface 
should be rubbed briskly through the sheet, and from time to time 
cold water is freely sprinkled over the sheet. Friction must be con- 
tinued during the pack, and ice cloths or cap placed on the head. 
The duration of the cold pack is determined by the temperature and 
the reactive powers of the patient. It is often well to administer an 
alcoholic stimulant or a hypodermic injection of strychninae sulphas 
before the pack and, may be, after. 

The cold bath, after the method of Brand, or " tubbing," has proven 
most prompt and decided for reducing temperature. It consists in 
the systematic employment of general cold baths, with frictions when- 
ever the temperature reaches 102. 2 F. As often as the temperature, 
taken every three hours in the mouth or rectum, is over 102. 2 , the 
patient receives a bath lasting fifteen or twenty minutes. He wears a 
thin muslin garment or is wrapped in a sheet ; he is given a stimulant 
and carefully lifted into the bath of 65 or jo°, some cold water being 
poured over his head and shoulders to lessen the shock ; the head 
rests on an air pillow, the body submerged to the neck. During the 
whole period of the bath the patient must be briskly rubbed. The 
friction and affusion are of value in preventing chill and cyanosis. 
After the bath the wet linen is quickly removed and the patient placed 
in bed wrapped in a dry sheet and covered with a blanket. A stimu- 
lant is again given after the bath, and if a tendency to cyanosis or heart 
failure, a hypodermic injection of strychnina. The temperature is 
taken after the patient is placed in bed and again in half to three- 
quarters of an hour, and if not then 102 , is not again taken for three 
hours. The good effects of the bath are seen in a reduction of tem- 
perature, clearer intellect, and lessening stupor and muscular twitch- 
ing. Sleep usually follows a bath, with a general stimulating effect 
upon the heart and the nervous system. There are no counter- 
indications to the cold bath save intestinal hemorrhage. 



FEVERS. 31 

Diarrhaza should not be checked unless it exceeds three or four 
stools in twenty-four hours, when may be used — 

K. . Bismuth, subnit., gr. xx 1.3 Gm. 

Acid, carbol., Try .06 Cc. 

Tinct. opii deodorat. , ttl xv *■ ^ c - 

Mucil. acacia;, f^j 4. Cc. 

Aquas, f^iij 12. Cc. M. 

SlG. — Every three or four hours. 

Or— 

l£ . Cupri sulph., ...» gr. ]/e .011 Gm. 

Extracti opii, g r - X • OI ^ Gm. M. 

SlG. — In pill, every four hours. 

At the onset of a suspected case of typhoid fever, when there are 
present coated tongue, fetid breath, anorexia, chilliness followed by 
feverishness or fever, nervousness, costiveness or frequent tenesmic 
stools, and general soreness associated with mental unrest and head- 
ache, excellent results follow the use of the following combination : 

R . Hydrargyri chlor. mite, .... gr. viij .52 Gm. 

Sodii bicarbonatis, gr. xv I. Gm. 

Pulv. ipecacuanha;, gr. Ij .13 Gm. 

Salol, ............ gr. xv I. Gm. M. 

Ft. chart. No. xv. 

Sig. — One powder every three hours until decided bowel action. 

Or— 

r£ . Salol, gr. iij .2 Gm. 

Bismuth, salicyl., basic, . . . . gr. v .3 Gm. M. 

Sig. — In powder, after each stool. 

Or— 

H< . Acid, sulph. aromat, TTLxv I. Cc. 

Tinct. opii deodorat., rr\_x .6 Cc. 

Sig. — In water, every three hours. 

For Tympanites : cold compresses or an ice-bag to the abdomen, 
or a turpentine stupe is of value. Page recommends the gentle 
introduction of a catheter far up the rectum to relieve a powerless 
bowel, as urine is drawn from a paralyzed bladder. Tympany 
with constipation is relieved by the use of olei terebinthince, rr^x 



32 PRACTICE OF MEDICINE. 

(0.6 Cc), olei ricini, rr^xv (1 Cc), in emulsion every three or four 
hours. 

For Thirst: cooling drinks in moderation, or pellets of ice slowly 
dissolved in the mouth, and washing mouth, lips, and tongue fre- 
quently with cold water is acceptable. 

Headache : cold to the head, mustard to the neck, and foot baths ; 
if these fail to relieve, morphina or atrophia hypodermically, and 
rarely leeches to the temples may be needed. 

Delirium : if from debility, increase the stimulants ; other causes, 
use morphina if the delirium is active. 

Insomnia : if of long duration, use trional, gr. xv-xxx (1-2 Gm.). 

Restlessness and coma vigil : stimulants and an ice cap. 

Debility : food every two or three hours ; do not permit sleep to in- 
terfere with nourishment. Stimulants are indicated early, the best 
guide being the heart's action ; an average amount would be spiri- 
tus frumenti y fgss (15 Cc.) every three hours, but the amount and fre- 
quency of the dose must be guided by the condition of the heart, 
pulse, and general prostration. Spiritus ammonicz aromaticus , f^j 
(4 Cc.) every couple of hours in milk or water, is a valuable stimu- 
lant and stomachic tonic. Spiritus chloroformi, n\,ij-v (0.12-0.3 Cc) 
every hour or two, is also a valuable stimulant. 

The bladder should be examined at each visit. 

Intestinal hemorrhage : at once morphina, hypodermically, and 
ext. ergotce fid., f£j (4 Cc), repeated p. r. n., or MonseTs solution, 
TT\,v-x (0.3-0.6 Cc.) every two hours, or olei terebinihince, rr^x (0.6 Cc), 
and cold to the abdomen. 

Perforatio)i and peritonitis : at once morphina sulphas, gr. x / z 
(0.032 Gm.), hypodermically, followed by extrachim opii, gr. j (0.065 
( mi.) every hour, hot applications to the abdomen, and bold stimula- 
tion. 

lobar pneumonia and bronchial catarrh : dry cups and the use of 
the following: 

\i . Ammonii chlorid., ^ij 8. Gm. 

Strychninae sulph , Q r - l A ° 2 Gm. 

Spts. chloroformi, f zj 4. Cc. 

Aq. lauro-cerasi, . . . q. s. ad f^iv 120. Cc. 

SlG. — Dessertspoonful every two, three, or four hours, diluted. 

In cases in which the tongue is dry, brown, and with a tendency 



FEVERS. 33 

to fissure, excellent results are obtained from turpentine in emul- 
sion : 

R. Olei terebinthinse, f3 ss T 5- Cc. 

Mucil. acacioe, q. s. q. s. 

01. sassafras, T^lxv I- Cc. 

Aq. chloroformi, . . . q. s. ad f 5 iv 120. Cc. M. 
One teaspoonful every two or three hours, diluted. 

In patients with whom the above disagrees, good results are ob- 
tained from acidum hydrochloricum dilutum or one of the other of the 
mineral acids, in doses of tt\,xv (0.9 Cc), well diluted every three or 
four hours. 

During the entire course of the disease use strychnines sulphas, 
gr.^ (0.002 Gm.), every four hours. 

Convalescence : The patient must be most guarded in exercise or 
mental occupation. Liquid diet for ten days to two weeks after nor- 
mal afternoon temperature. Cardiac palpitation and excessive sweat- 
ing are not infrequent, and can be controlled by a combination of 
quinina and belladonna. If the stools continue quite liquid with a 
little bright blood now and then, showing some remaining ulceration, 
use argentum nitras in pill form with nucis vomica or strychnina. 
The addition of extract of malt or porter to the diet is of value in a 
prolonged convalescence. 

TYPHUS FEVER. 

Synonyms. Contagious fever ; ship fever ; jail fever ; exanthe- 
matic typhus (German) ; petechial typhus ; spotted or putrid fever. 

Definition. An acute, infectious, febrile, epidemic disease ; highly 
contagious, and characterized by sudden invasion, profound depres- 
sion of the vital powers, sickening odor, and a peculiar maculated 
and petechial eruption, favorable cases terminating by crisis about 
the fourteenth day. No lesion. 

Cause. A special infecting germ, the character of which is un- 
known, but which is influenced by filth and overcrowding. Rarely 
seen in the United States except in seaports, where brought by emi- 
grants. 

Pathology. No constant lesion peculiar to the affection. Blood 
is profoundly altered, dark, thin, with lessened fibrin ; tissues dark, 
soft, and flabby. 
4 



34 PRACTICE OF MEDICINE. 

Symptoms. Begins abruptly ; chill followed by violent ftver, 
temperature within a few days reaching 104 to 105 F. ; a frequent, 
bounding pulse, soon becoming small, weak, and rapid ; the cardiac 
impulse and first sound almost effaced, severe headache, followed by 
violent delirium ; from the fifth to the seventh day, a coarse, red, 
diffused, measly eruption, with a mottling of the skin all over the 
body, except the face, not disappearing on pressure ; the face has a 
uniform deep, dusky flush, the skin has a glazed appearance, the 
pupils are contracted, the eyes injected. With the development of 
the disease there is cuta)ieous hyperesthesia, muscular soreness, and 
le?iderness over the tibia. There is great prostration, great muscular 
feebleness, vertigo, tremor, and subsultus ; constipation the rule. End 
of the second week, the temperature suddenly declines and the 
patient passes into a rapid convalescence \ 

Complications. Pneumonia and swollen parotid glands are 
common. 

Diagnosis. From typhoid fever, the age, season, onset of the 
disease, temperature record, character of the eruption, and the intes- 
tinal symptoms. 

Measles begin milder, with coryza and cough, and never have such 
pronounced nervous phenomena, but there occurs an early eruption, 
appearing on the face. 

Cerebrospinal fever has many symptoms in common, and but for 
the rarity of typhus in this country would be more puzzling. The 
headache and rigidity of the muscles of the neck are much more pro- 
nounced in cerebro-spinal fever and the prostration less than in 
typhus fever. The eruption of typhus is characteristic and should 
prevent error. 

Prognosis. Unfavorable indications : high temperature, frequent 
pulse, early stupor, presentiment of death. Favorable : youth, mod- 
erate temperature and pulse, and mild nervous phenomena. 

The duration about two weeks ; mortality varies from five to thirty- 
five per cent. 

Treatment. Symptomatic. As typhus fever is distinctly conta- 
gious, isolation is imperative, with immediate removal and disinfection 
of the patient's excreta. 

All cases are benefited by small doses of the mineral acids alternat- 
ing with quinines sulphas. 

For high temperature, cold sponging, cold pack, or full doses of 



FEVERS. 35 

quinince sulphas. Also the systematic use of the cold bath or " tub- 
bing," as now employed in typhoid fever. 

For the headache and delirium cold to the head. In the young 
and strong, a few leeches to the temple, and chloral, with or without 
the bromides. 

For constipation, mild laxatives. 

Debility : alcohol early and in full doses, or spiritus chloroformi'm. 
drachm doses whenever danger of collapse. 

Convalescence : such tonics as quinina and strycJmina. 



CEREBROSPINAL FEVER. 

Synonyms. Epidemic cerebro-spinal meningitis ; epidemic cere- 
brospinal fever ; spotted fever ; cerebro-spinal typhus. 

Definition. A malignant epidemic fever, characterized by head- 
ache, vomiting, painful contractions of the muscles of the back of 
the neck, retraction of the head, hyperesthesia, disorders of the 
special senses, delirium, stupor, coma, and frequently an eruption of 
petechiae or purpuric spots — a subcutaneous extravasation of blood. 
Lesions of cerebral and spinal membranes are found at the post- 
mortem. 

Cause. A special micro-organism, of oval shape, occurring mostly 
in pairs and faintly tremulous, resembling those found in pneumonia 
and erysipelas, though hardly identical. Bad hygiene seems to favor 
the development of this affection, but can hardly be considered its 
cause. 

The disease seems to have a predilection for the young. Occurs 
most frequently in the winter months. Slightly if at all contagious. 

We have no positive knowledge of the manner in which the virus 
gains entrance into the system. 

Pathological Anatomy. The extent of lesion present in a 
given case depends upon the duration of the illness. In cases rapidly 
fatal it is probable that the individual is overwhelmed by the poison 
ere the characteristic anatomical changes have had time to develop. 

The changes in this disease are twofold : those due to the direct 
action of the infecting poison upon the blood, producing the group of 
symptoms constituting the fever and complications, and those giving 
rise to the local inflammation — viz., hyperemia of the membranes of 



36 PRACTICE OF MEDICINE. 

the brain and spinal cord, followed by an exudation of lymph and an 
effusion of serum, resulting in pressure upon the brain and cord. The 
inflammatory changes are more marked in the membranes at the 
base of the brain than elsewhere. The lungs, spleen, stomach, liver, 
kidneys, and bladder are in various stages of congestion. 

If the patient survive long enough, inflammatory changes occur in 
the cranial and special nerves and the organs of special sense. 

Symptoms. Divided, according to the severity of the lesion, 
into three groups : the conwion form, the fulminant, and the abortive. 

The Co7iimo7i Form begins abruptly with a chill, excruciating head- 
ache, persistent nausea, vomiting, vertigo, and an overwhelming sense 
of weakness. Within a few hours the muscles of the back of the 
neck become rigid and retracted (tonic spasm), with decided pain 
upon moving the head ; this rigidity and retraction soon extends to 
the back, when opisthoto?ncs occurs. There is great restlessness, and 
the surface of the body becomes highly sensitive (^hyperesthesia). 
Cramps in the muscles of the legs and elsewhere, and spasmodic 
twitchings of the lips and eyelids come and go, and, finally, convul- 
sions or delirium occur. Intolerance of light, and in some cases 
amaurosis, more or less deafness, loss of sense of smell and taste 
soon following. The temperature and pulse records are irregular. 
From the first day to the fifth an eruptio?i of petechias or purpura 
occurs in the majority of cases, and also an herpetic eruption, begin- 
ning as herpes labialis, appears. The tache ck>ebrale is usually to be 
obtained. The disease reaches its height in from three to eight days, 
and passes into stupor and coma, or ameliorates and passes into a 
protracted convalescence. 

The Fulminant Form. Severe chill, depression, and in a few hours 
collapse. The patient is overcome by the poison and never reacts. 

The Abortive Form consists of one or more pronounced character- 
istic symptoms during the course of an epidemic. 

Complications. Pneumonitis; endocarditis; pericarditis; typhoid 
fever; pleuritis ; intestinal catarrh in infants. 

Sequelae. Result from thickening of either the cerebral or spinal 
membranes. Persistent headache ; blindness, or deafness, partial or 
complete; mental feebleness; chronic hydrocephalus; epilepsy, or 
different forms of spinal palsies. 

Diagnosis. Typhoid fever begins slowly, has a characteristic 
temperature record, without so intense headache, and muscular 



FEVERS. 37 

rigidity, opisthotonus, vomiting, and early delirium, not ending in 
coma. 

Typhus fever has higher temperature, is of longer duration, and has 
a peculiar measly eruption, is not attended with muscular rigidity and 
retraction, hyperaesthesia, nor disorders of the special senses. 

Tubercular meningitis is not epidemic, has no characteristic erup- 
tion ; is preceded by long prodromes, and runs a tedious course. 

A congestive chill resembles the fulminant cases in suddenness of 
depression, but the latter has not the history of the former. 

Inflammation of the meninges of the cord is due to exposure to 
cold or syphilis, and is not attended with cerebral symptoms or an 
eruption. 

Small-pox in the first days, with the severe lumbar pains, headache, 
vomiting, and rash, may cause error. 

Prognosis. Varies according to epidemic ; from twenty to fifty, 
and even seventy-five per cent. die. 

Treatment. There is no abortive plan of treatment for cerebro- 
spinal fever, nor can the antiphlogistic treatment for the inflammatory 
symptoms be advised. Like the infectious diseases in general, sus- 
taining measures are indicated in all but the most sthenic cases. 

Nutritious and easily assimilated food, such as milk, eggs, meat- 
juice, and broths, should be given at regular intervals night and day. 
If food cannot be taken by the mouth, nutritious enemata should be 
substituted. 

The drug that holds the highest place in the treatment of this dis- 
ease is opium. The hypodermic use of morphines sulphas, gr. ]i~Yz 
(0.016-0.032 Gm.) every two or three hours, or exir actum opii, gr. j 
(0.065 Gm.) eveiy hour until the stage of effusion, when quinines 
sulphas in tonic doses, and potassii iodidum are indicated. Prof. Da 
Costa alternates potassii bromidum with opium, especially in children. 
Ergota in the early stages would seem to be indicated, but in prac- 
tice it is of little or no value. For the convulsions or spasms that 
are so often present no remedy is comparable with chloral, gr. xxx 
(2 Gm.), repeated as indicated. 

Caution in the use of the coal-tar products must be exercised, as 
the relief of pain and spasm may be the onset of the stage of collapse 
instead of the beneficial effects of these drugs. 

Locally, cold compresses to the head and spine is a most valuable 
measure, continued for hours at a time. 



38 PRACTICE OF MEDICINE. 

For sequelce, potassii iodidum, a course of hydrargyrum, oleum 
morrhua, and flying blisters along the spinal column, or touching the 
back of the neck with the Paquelin cautery. 



RELAPSING FEVER. 

Synonyms. Febris recurrens; famine fever; bilious typhoid 
fever; spirillum fever. 

Definition. An acute infectious, contagious, epidemic, febrile 
disease, self limited, characterized by a febrile paroxysm, lasting 
about six days, succeeded by an entire intermission of the same dura- 
tion, which is in turn followed by a relapse similar to the first seizure. 
Associated with alterations in the viscera, and by the presence in the 
blood of a specific micro-organism — the spirillum of Obermeyer. No 
specific lesion. 

Cause. A specific poison; contagious; acquiring the greater 
activity the more filthy, crowded, and unhealthy the population amid 
which it prevails. 

Pathological Anatomy. During the febrile paroxysm only, the 
blood contains minute corkscrew-shaped organisms or spiral fila- 
ments, — spirilli, constantly twisting and rotating, — the spirillum Ober- 
meicri. The spleen is enlarged and usually covered with a fresh 
fibrinous exudation. The capsules present a mottled appearance. 
The splenic pulp is more or less softened and swollen and shows en- 
larged Malpighian bodies. The liver and kidneys are swollen and 
congested. 

Symptoms. No prodroines. Onset abrupt, with fever, 102 - 
104 ; frequent, rather weak pulse, headache, nausea, vomiting, and 
lancinating pains in limbs and muscles, marked in the calf of the leg; 
second day, feeling of fullness and pressure in right and left hypo- 
chondrium, due to swollen liver and spleen ; jaundice is frequent ; 
seventh day fever ends by crisis ; fourteenth day symptoms return in 
milder form, continuing about four days, when enters slow convales- 
cence, much emaciated. No eruption. Several relapses may occur. 

Diagnosis. Yellow fever has many points of resemblance, but 
has a shorter febrile stage, remission not so complete, vomiting late 
and characteristic, normal spleen, and the late appearance of yellow 
color. 



FEVERS. 39 

Remittent fever 'begins with a decided chill, followed by fever and 
sweats, and not the progressive rise of temperature until the fifth or 
seventh day. 

Prognosis. Recovery the rule, but protracted, and decided 
emaciation results. 

Treatment. Expectant. Act on the secretions ; nourish patient 
and meet urgent symptoms. For fever, antipyretic doses of quinince 
sulphas which, however, has no power to prevent the relapses ; for 
pain, hypodermic injections of morphines sulphas ; for nausea and 
vomiting, acidum carbolicum or cerii oxalas ; during remission, fer- 
ritin and quinince sulphas in tonic doses. 



PERIODICAL FEVERS. 

These affections are characterized by the distinct periodicity of the 
phenomena, having intervals during which the patient is wholly or 
nearly free from fever. 



INTERMITTENT FEVER. 

Synonyms. Ague ; chills and fever; malarial fever ; swamp fever. 

Definition. A paroxysmal fever, the phenomena observing a 
regular succession ; characterized by a cold, a hot, and a sweating 
stage, followed by an interval of complete intermission or apyrexia, 
varying in length according to the variety of the attack, and the 
presence in the blood of a protozoon, known as the Plasmodium 
malaria. 

Cause. The presence in the blood of a specific vegetable micro- 
organism. Klebs and Tommasi-Crudeli claim to have isolated a 
germ — Bacillus malaria — from the low-lying atmosphere over 
marshes and from the soil, which produced a malarial paroxysm with 
enlarged spleen in an inoculated rabbit. 

Laveran discovered a germ in the human blood of patients suffer- 
ing from malarial fevers which is now known as the hcematozoa of 
Laveran, and which has since been found always present in malarial 
attacks. These germs are true parasites and exhibit several varieties 
of form and size, and it is possible that there may be several species 



40 PRACTICE OF MEDICINE. 

which are capable of causing the distinct types of the disease, as ter- 
tian, quartan, intermittent, or remittent. 

Laveran describes the chief forms of the hsematozoa as consisting 
of amoeboid spherical bodies with nuclei ; crescentic shapes with 
nuclei; rosettes; and fiagellate bodies. Laveran considers the para- 
sites as a single but polymorphic organism, and a particular form of 
the germ is peculiar to a particular type of the disease. Osier, who 
has devoted much time to the study of the subject, "believes that 
different forms of the germ belong to distinct species, and that they 
are not all different stages in the development of one microbe." 

The period of incubation varies from a few days to weeks, months, 
or even years, an auxiliary condition, such as exposure to cold, over- 
exertion, excesses in eating and drinking, or great excitement, often 
being necessary to give efficiency to the special cause. 

Either sex and all ages are susceptible to the poison. 

The mode of infection is not positively understood. It often enters 
the system in the inspired air, and no doubt also in contaminated 
drinking-water or other fluids. 

Pathological Anatomy. Blood dark, from the formation of 
pigment (Afelanczmia). Spleen engorged and swollen {Ague cake). 
Liver swollen and engorged during paroxysm. 

Varieties. Quotidian when a daily paroxysm ; tertian when 
every other day ; quartan when it occurs first and fourth days ; octaii 
when weekly; duplicated quotidian when two paroxysms daily; 
duplicated tertian, two every second day ; double te?'tian, daily 
paroxysm, but more severe every second day. Dumb ague, or 
masked ague, presents irregularity of the characteristic phenomena. 

Symptoms. Each paroxysm has three stages — the cold, hot, and 
sweating. 

Cold stage begins with prodromes, lassitude, yawning, headache, 
and nausea, followed by a chill ; the teeth chatter, skin pale, nails 
and lips blue, the surface rough and pale, the so-called goose-skin, 
or cutis anserina, nausea, and great thirst, while the thermometer in 
the axilla or mouth shows a decided rise of temperature, io2°-io_l° F. ; 
these phenomena continuing from one half to an hour. 

Hot stage begins gradually, the shivering ceases, the surface be- 
comes hot and flushed, the temperature rising to 106 F. or moie, 
pulse full, headache, nausea, intense thirst, dry, flushed, swollen skin, 



FEVERS. 41 

scanty urine, and other phenomena of pyrexia, continuing from one 
to eight or ten hours. 

Sweating stage begins gradually, first appearing on the forehead, 
then spreading over the entire surface; the fever lessens, the tem- 
perature rapidly falling to 99 or 98 , pulse less full, headache lessens, 
and a general feeling of comfort exists, sleep often following; dura- 
tion of the sweating from one to four hours, when the intermission 
occurs, the patient apparently well, except for a feeling of general 
debility. 

The occurrence of the next paroxysm depends upon the variety of 
the attack. 

The paroxysm may be ushered in by a decided pain in one or 
more nerves, instead of the cold stage, to wit : " brow ague." 

Diagnosis. No difficulty when the characteristic chill, fever, and 
sweats occur and enlarged spleen, and the presence of the organism 
in the blood. 

Hectic fever. Distinguished by its irregularity, and occurring 
secondary to an organic disease ; spleen usually normal size, and 
absence of the organism in the blood. 

Pycemia produced by other causes than malaria. 

Nervous chills show an absence of the temperature rise. 

Prognosis. Recovery the rule. Without treatment many cases 
end favorably after several paroxysms, others passing into the chronic 
form, or malarial cache xice. 

Treatment. Cold stage can be averted and the other stages 
greatly modified by a hypodermic injection of either morphines 
sulphas, gr. l /%-]i (0.008-0.016 Gm.), or pilocarpines hydrochloras, 
gr. yi (0.008 Gm.), or chlorofornii spts., fgj (4 Cc), by the stomach. 
Hot stage, cool drinks and cold sponging. Sweating stage : when ex- 
cessive, sponging with alumen and hot water. 

Intermission : at once a brisk purgative, followed by cinchona in 
some form, the most efficient being quinines sulphas, gr. xvj-xxiv 
(1-1.6 Gm), in solution or freshly made pills, in one or two doses, 
three to five hours before the expected paroxysm. Many substitutes 
are lauded to replace the salts of cinchona bark, but without a doubt 
quinina is a specific in the strictest sense of the term. 

Free action on the bowels is essential to success, a good combina- 
tion being hydrargyri chloridi mitis, sodii bicarb., aa gr. v (0.32 
Gm.), followed by an active saline. 



42 PRACTICE OF MEDICINE. 

After the paroxysms are broken up use liquor potassii arsenitis, 
n\,v-x (0.3-0.6 Cc), for a long time, or tinct. ferri chloridi, n\,xx 
(1.3 Cc), every four hours or a combination like the following : 

R . Ferri reducti, 

Quininoe sulph. , aagr. lx 4. Gm. 

Acidi arsenosi, gr. j .065 Gm. 

01. pip. nigr., ti\xv 1. Cc. M. 

Ft. pil. No. xxx. 

Sig. — One pill after meals, continued for one month or longer. 

Relapses being common, quinines sulphas should be given on the 
second or third day, fourth to the sixth, twelfth to the fourteenth, 
and ninetee?ith to the twenty-first days. 

If the spleen be enlarged, — and it usually is in long-continued cases 
or those becoming chronic (marked anaemia, gastric distress, consti- 
pation with depression of spirits associated with headache coming in 
paroxysms are the prominent symptoms of the cachexia), — use locally 
ung. hydrargyri iodidi rubri, and internally ergota, or ergotine (aq. 
ext.), hypodermically over the splenic region, and tonic doses of 
quinina, ferrum, and arse?iicum. 

REMITTENT FEVER. 

Synonyms. Bilious fever ; bilious remittent fever ; marsh fever ; 
typho-malarial fever. 

Definition. A paroxysmal fever, with exacerbations and remis- 
sions, but in which the temperature is constantly above the normal ; 
characterized by a moderate cold stage (which does not recur with 
each paroxysm) ; an intense hot stage, with violent headache and 
gastric irritability ; and an almost imperceptible sweating stage, which 
is frequently wanting. 

Cause. The presence in the blood of a specific vegetable micro- 
organism, either the Bacillus malaria (Klebs and Tommasi Crudeli), 
or the hcEmatozoa of Laveran {vide Intermittent Fever). 

Pathological Anatomy. Blood dark (Melan&mia) ; spleen 
enlarged, soft, filled with blood, and of an olive color ; liver congested 
and swollen, and of a bronze hue ; the brain hyperaemic and olive- 
colored ; gastro-intestinal canal markedly hyperaemic. 

Symptoms. Cold stage : moderate chill, the temperature rising 



FEVERS. 43 

one or two degrees, coated, dry tongue, oppression at the epigastrium, 
slight headache, and pains throughout the body. 

Hot stage : persistent vomiting, furred tongue, full pulse, rising to 
100 or 120, flushed face, injected eye, violent headache, pains in limbs 
and loins, hurried respiration, the temperature rising to 104 F., or 
106 . The bowels costive, stools tarry and offensive, the urine scanty, 
high colored and ureaic, and the surface becoming yellowish. Deli- 
rium occurs when the temperature is very high. 

Sweating stage : after six to twenty-four hours the above symptoms 
abate and slight sweating occurs, the pulse, headache, and vomiting 
subside, and the temperature falls to ioo° F., or 99 F. 

This is the remission, during which the symptoms of a mild pyrexia 
are present. 

After some two to eight or twelve hours the symptoms of the hot 
stage return, generally minus the chill, and this is termed the 
exacerbation, which is in turn again followed by the remission. 

Duration. From seven to fourteen days the average. Fre- 
quently the fever ceases to re?nit, and instead becomes continuous, 
the symptoms resembling, if they are not identical with, the typhoid 
state, whence the term typho-malarial fever, or malario-typhoid fever. 

Sequelae. The malarial cachexia results when the poison has 
not been eliminated from the system. 

Persistent headache and vertigo are the results of the intense 
meningeal hyperemia that sometimes occurs. 

Diagnosis. In intermittent fever each paroxysm begins with a 
chill, while the chill seldom recurs in remittent fever; a distinct 
intermission follows each paroxysm of the intermittent form, while a 
remission occurs in remittent, the thermometer showing that the fever 
does not wholly disappear ; during the intermission the patient is appa- 
rently well ; such is not the case in the remission of intermittent fever. 

Typhoid Fever is mistaken for remittent fever, but the absence of 
the characteristic temperature record, diarrhoea, eruption, tympanites, 
deafness, severe prostration, and the Widal reaction, with the pres- 
ence in blood of the malarial organism, should prevent such an error, 
as a diagnosis can always be made with absolute certainty by an 
examination of the blood. 

Prognosis. Uncomplicated cases are favorable. 

Treatment. Quinines sulphas, gr. xvj-xx (1-1.3 Gm.) per diem, 
is the remedy. Better administered during the remission, if possible. 



gr. v 


.3 Gm. 


gr. v 


.3 Gm. 


gr. ss 


.03 Gin. 



44 PRACTICE OF MEDICINE. 

If an irritable stomach prevents its administration by the mouth, 
use it by the hypodermic method or in a suppository. During the hot 
stage, cool sponging, cold to the head, and if a tendency to cerebral 
congestion, dry or wet cups to the nape of the neck and — 

R. Tinct. aconit. rad. TTljj .12 Cc. 

Liq. potassii citrat., fgij 8. Cc. 

Liq. ammon. acetat., f 3 ij 8. Cc. M. 

Every two hours. 

During the remission relieve the intestinal canal with — 

R . Hydrargyri chlor. mitis, . . 

Sodii bicarb. , 

Pulv. ipecac, gr. ss .03 Gm. M. 

In pulv. p. r. n. 

The same precautions are essential after the paroxysms are broken 
up to prevent their return on the septenary periods that were recom- 
mended for intermittent fever. 

It is but fair to mention the statement of Koch, seconded by Hare, 
that quinina is a nephritic irritant, but if so, it must be in toxic 
amounts, which are not recommended. 

For convalescence : Ferritin, arsenictim, and sirychnina are indi- 
cated. 

PERNICIOUS MALARIAL FEVER. 

Synonyms. Congestive fever; malignant intermittent fever; 
malignant remittent fever ; the congestive chill. 

Definition. A malignant, destructive malarial fever, which may 
be of the intermittent or remittent form; characterized by intense 
congestion of one or more internal organs, together with dangerous 
perversion of the functions of innervation. 

Cause. A high degree of malarial poison. {Vide Intermittent 
Fever.) 

Varieties. Gastro-enteric ; thoracic; cerebral ; hemorrhagic; 
algid. 

Symptoms. Any of these varieties may begin either as an inter- 
mittent or remittent fever; again, the first paroxysm is rarely per- 
nicious, but appears as the ordinary malarial attack. 



FEVERS. 45 

The gastro-enteric variety has, as distinctive features, intense nausea 
and vomiting, purging of thin discharges mixed with blood, tenesmus, 
burning heat in stomach, intense thirst, frequent, weak -pulse, face, 
hands, and feet cold, with shrunkefi features, and an intense depres- 
sion of all the vital forces. This condition continues from half an 
hour to several hours, when either an inter- or a remission occurs. 

Thoracic variety often combined with the one just described. Its 
characteristic features are due to overwhelming congestion of the 
lungs, such as violent dyspnoea, gasping for air, fifty to sixty respira- 
tions per minute, oppressed cough with slight amount of blood-streaked 
sputa, frequent, weak pulse, cold surface, and terror-stricken features. 
Duration same as the above. 

Cerebral variety, due to intense congestion of the brain ; sometimes 
effusion of serum into the ventricles, or even rupture of small blood- 
vessels. Characterized by violent delirium, followed by stupor and 
coma, slow, full pulse, the surface either flushed or livid. Cases may 
either resemble apoplexy — comatose variety — or acute meningitis — 
delirious variety. Duration same as the other forms. 

Hemorrhagic variety, or the yellow disease, as it has been termed, 
begins as an ordinary inter- or remittent fever, soon followed by signs 
of internal congestion, to wit : nausea, vomitmg, dyspnoea, severe 
pains over liver and kid?iey, continuing for a few hours, when the 
surface suddenly turns yellow and bloody urine is voided, after which 
an inter- or a remission and marked abatement occur, to be sooner or 
later followed by a second paroxysm, which is more severe, with signs 
of cerebral congestion. Blood may also escape from other parts than 
the kidneys. 

Algid variety is characterized by intense coldness of the surface, 
while the rectal temperature ranges from 104 to 107 F. The attack 
begins with a chill, which is soon followed by fever of variable dura- 
tion, when the body becomes cold, the axillary temperature falling to 
90 , 8S°, or even 85 F., a cold sweat covers the surface, the tongue 
is white, moist, and cold, the breath is icy, the voice feeble and 
indistinct, the pulse slow, feeble, and often absent at the wrist, and 
with all these symptoms, the patient complains of a sensation of 
burning and intense thirst. The mind is clear, but the countenance 
is death-like. 

Duration. Pernicious malarial fever, in any of its forms, may 



46 PRACTICE OF MEDICINE. 

continue from a few hours until one, two, or three days. Recovery- 
is rare after a second, almost never after a third, paroxysm. 

Diagnosis. A positive diagnosis can always be made by an 
examination of the blood. 

Yellow fever is most apt to be confounded with the hemorrhagic 
variety, and as they both occur in the same localities, the diagnosis 
is difficult; the early yellowness of the surface, with hematuria and 
the absence of the black vomit and epidemic prevalence, are the 
chief points of distinction. 

The cerebral variety may be mistaken for cerebral apoplexy, men- 
ingitis, and urcemic convulsions. Nor is it always an easy matter to 
differentiate between these conditions. 

The gastro-enteric variety may be mistaken for the early stage and 
the algid variety for the later stage of cholera, but the epidemic 
prevalence of the latter should be of material aid in determining the 
diagnosis. 

Prognosis. In all varieties the result is unfavorable, unless it 
can be controlled prior to the second paroxysm. Cases in which an 
intermission occurs are better controlled than where a remission 
follows. The mortality is one in eight from all plans of treatment. 

Treatment. The first indication in all varieties is to bring about 
reaction. In the cold stage, heat to the surface, and stimulating 
lotions ; in the hot stage, cold to the surface and the hypodermic injec- 
tion of morphince sulphas, gr. % (0.016 Gm.), at once. After reaction, 
quinina? sulphas, not less than gr. xl (2.6 Gm.), repeated p. r. n.; 
administer by stomach, rectum, or, better still, by hypodermic injec- 
tion. Dr. Bartholow pronounces the following one of the best formuke 
for the hypodermic use of quinina : 

li . Quininae disulph., gr. 1 3.3 Gm. 

Acid, sulph. dil., rr\ c 6. 15 Cc. 

Aquae font, f^j 30. Cc. 

Acid, carbol. liq., V(\y .3 Cc. M. 

The new salt, quinina bimuriatica carbamidata, is highly recom- 
mended for hypodermic use, being very soluble. 

The following formula, known as " Warburg's Tincture," has 
(luring the last few years gained considerable reputation in the 
various forms of malarial fevers : 



FEVERS. 4 J 

R . Rad. rhei, P. aloe soc. , and Rad. 

angelica officinalis, ... aa ^ iv 120. Cc. 

Rad. helenii, Crocus Hipsan., 

Sem. fceniculi, and Creta prse- 

parat., aa ^ ij 60. Cc. 

Rad. gentian, Rad. zedoar, P. 

cubeb, G. myrrh, G. camphor, 

and Boletus Laricis, ... aa %') 30. Cc. 

Confect. damocratis,* ^iv 120. Cc. 

Quininse sulph. , J lxxxij 2460. Gm. 

Spts. vini rect., Oxx 600. Cc. 

Aquae purse, Oxij 360. Cc. M. 

Macerate in a water bath twelve hours, express, and filter. 

Each half ounce (15 Cc.) contains quininse sulphas, gr. viiss 
(0.46 Gm.). If the stomach is too irritable to retain the tincture, the 
tincture may be evaporated to dryness and administered in capsules, 
each containing the equivalent of either one or two drachms. 

For the gastro-enteric variety, Prof. Da Costa suggests : 

rj< . Morph. sulph., gr. 14 .016 Gm. 

Pulv. camph., gr. j .065 Gm. 

Mass. hydrarg. , gr. ij .12 Gm. 

Pulv. capsici, gr. ss .03 Gm. M. 

In pills every half hour until the character of the stool is changed. 

For the thoracic variety, dry or wet cups and ammonii carbonas, 



* Formula of Confectio damocratis : 

Cinnamon, 14. Gm. 

Myrrh, 11. Gm. 

White agaric, Spikenard, Ginger, Spanish saf- 
fron, Treacle, Mustard seed, Frankincense, 
and Chian Turpentine, aa 10. Gm. 

Camel's hay, Costus arabacus, Zeodary, Indian 
leaf, Mace, French lavender, Long pepper, 
Seeds of harwort, Juice of rape cistus, 
Strained storax, Opponex, Strained galba- 
num, Balsam of Gilead, Oil of nutmeg, Rus- 
sian castor, aa 8. Gm. 

Water germunder, Balsam tree fruit, Cubeb, 
White pepper, Seeds of carrot of Crete, Poley 
mont, Strained bdellium, aa 7. Gm. 

Gentian root, Celtic hard, Leaves of Dittany of 
Crete, Red rose, Seeds of Macedonium, Parsley, 
Sweet-fennel seeds, -Seeds of lesser cardamon_, 
Gum arabic, Opium, aa 5. Gm. 

Sweet flag, Wild valerian, Anise seed, Saga- 
pernum, aa 3. Gm. 

Spigrul, St. John's wort, Juice of acacia, Cate- 
chu, Dried bellies of skunk, aa 2.5 Gm. 

Clarified honey, 915. Gm. 

The roots to be finely powdered and the whole mixed thoroughly. 



48 PRACTICE OF MEDICINE. 

spiriius ammonia aiomaticus, caffeina citrata, and hypodermic injec- 
tions of strychnine sulphas. 

For the cerebral variety, venesection, or cups or leeches to the 
neck, cold to the head, prompt purgation, and free action on the 
kidneys and skin. 

For the algid variety, warmth to the surface, hypodermic use of 
morphince sulphas and atrophia, and the free use of ammonii car- 
bonas and alcoholic stimulants. 

For the hemorrhagic variety, purgatives, morphines sulphas hypo- 
dermically, and either acidum sulfthuricum dil., acidum gallic, 
Af onset's solution, or terebinthina. 

The following is highly spoken of for hemorrhages : 

H- Ext ergotcefld., f£ ss 15. Cc. 

Acid, sulpli. dil., f^iss 6. Cc. 

Acid, gallic, 5{j 4. Gm. 

Syr. zingib., • . . . f^iij 12. Cc. 

Aquae, q. s. adf^iij ad 90. Cc. 

Sig. — Dessertspoonful every four hours, well diluted. 

After the paroxysms are controlled, a long course of ferrum and 
arsenicum, with quinina on the septenary days. 



1/ 

YELLOW FEVER. 

Synonyms. Yellow Jack; bilious malignant fever ; typhus icter- 
ode; Mediterranean fever ; sailor's fever ; black vomit. 

Definition. An acute, infectious, paroxysmal disease, of three 
stages — the febrile, the remission, and the collapse ; characterized by 
violent fever, yellowness of the surface, and " black or coffee-ground 
vomit." Tendency fatal ; one attack confers immunity from a sec- 
ond. Not contagious. 

Cause. A specific poison, existing only with a high temperature 
and destroyed by frost. Not due to the malarial poison. Usually 
seen during the months of June, July, August, and September. 

The true home of yellow fever is in the tropics. 

Guiteras mentions three areas of infection : 1. The focal zone in 
which the disease is never absent, including Havana, Vera Cruz, Rio, 
and other Spanish-American ports. 2. Peri-focal zone or regions of 
periodic epidemics, including the ports of the tropical Atlantic in 



FEVERS. 49 

America and Africa. 3. The zone of accidental epidemics, between 
the parallels of 45 north and 35 south latitude. 

Epidemics are due to the introduction of the specific germ, either 
from patients affected with the disease or through infected articles. 

Neither age, sex, race, nor social condition has immunity. One 
attack protects the individual. 

Pathological Anatomy. Skin lemon or greenish-yellow color, 
due to dissolution of the red blood corpuscles ; heart softened by 
granular degeneration ; stomach, veins deeply engorged, the mucous 
membrane softened, and containing more or less "coffee-ground" 
matter, which consists of blood corpuscles deprived of their haemo- 
globin, white corpuscles, epithelial cells, and debris. Intestines much 
the same as the stomach ; liver, yellow color and a fatty degeneration 
of the hepatic cells ; kidneys, granular degeneration of the epithelium 
of the tubules. The spleen presents a singular lack of pathological 
change. 

Symptoms. The incubation lasts from twenty-four hours to six 
and exceptionally ten days. The more severe the epidemic, the 
shorter the period of incubation. 

First stage, the febrile, beginning either with the prodromes of 
malaise, headache, and anorexia, or suddenly with a chill, high/ever, 
in a few hours reaching 104 to 106 F., rapid pulse, 90-100 beats, 
brilliant eye, flushed countenance, coated tongue, irritability of the 
stomach, and severe neuralgic pains in the head, limbs, epigastrium, 
back, and large joints. The patients are restless and anxious, with 
a feeling of general prostration. In severe attacks delirium is fre- 
quent. The urine is scanty, acid, high colored, and contains albu- 
min. A peculiar and characteristic odor is emitted from the patient. 
Duration of the first stage from thirty-six hours to three or four days. 

Second stage, the reniission, when the temperature declines to ioo° 
or 99 F., and all the distressing symptoms abate or subside, and 
with some critical evacuation convalescence occurs, or, more com- 
monly, after from a few hours to one to four days, the — 

Third stage, the stage of collapse, or the period of secondary fever, 
is ushered in by a return of all the symptoms of the first stage in an 
exaggerated form, followed by yellowness of the skin, passing to a 
deep mahogany color, black vomit, and hemorrhages from other parts, 
feeble pulse, cold surface, irregular respiration, and death from ex- 
haustion, the mind remaining clear until the end. 
5 



50 PRACTICE OF MEDICINE. 

The above symptoms represent a sthenic case ; other varieties are 
the algid, hemorrhagic ', and typhus. 

Duration. Depends upon the variety ; from a few hours to a few- 
days. Rarely continues longer than one week. 

Diagnosis. Pernicious fever, hemorrhagic variety, is apt to be 
mistaken for yellow fever. Yellow fever is a disease of one paroxysm 
and one remission, epidemic, with albuminuria and black vomit. 
Pernicious fever has more than one paroxysm, not epidemic, rarely 
black vomit or albumin in urine. A valuable diagnostic point from 
malarial fevers is that quinine has no similar influence over yellow 
fever. 

Prognosis. One in four perish. Short cases unfavorable, as are 
the hemorrhagic and algid varieties. 

Treatment. No specific : a " self limited '" disease. The indica- 
tions are to keep the patient quiet in bed, and to treat the symptoms 
as they arise, and to nourish the patient. Good nursing, ventilation, 
early emesis and purgation, with diaphoretics and diwetics, are 
apparently beneficial. Large doses of quinince sulphas, early in the 
attack, for high temperature, by hypodermic method. For the irrita- 
ble stomach, ice slowly dissolved in the mouth, and acidum carbolicum, 
gr. X (0.016 Gm.), in aqua menthce pip., every two hours, alternated 
with liquor calcis and milk, each an ounce ; or — 

R . Hydrargyri chlor. mite, .... gr. ^ .005 

Morphince sulph., gr. fa .003 M. 

Every two hours until nausea is controlled. 

Surgeon-General Sternberg suggests the following toward a specific 
action : 

R. Sodii bicarb. , gr. cl 10. Gm. 

Hydrargyri chloridi corr., ... gr. y^ .02 Gm. 

Aquce destillat., Oij 950. Cc. M. 

SlG. — Three tablespoon fuls every hour. 

For the black vomit and hemorrhages, either liquor ferri subsul- 
phatis or plumbi acetas. The pains, restlessness, or delirium are best 
controlled by the hypodermic use of morphince sulphas or atrophia?. 
Free stimulation from the onset is needful. 

When an epidemic of yellow fever breaks out all persons whose 
duty does not keep them with tlie sick should leave the infected dis- 



FEVERS. 51 

trict at once. " The cardinal principles involved in prophylaxis dur- 
ing an epidemic are summed up in the oft-quoted words, 'Isolation, 
disinfection, and depopulation.' " 



ERUPTIVE FEVERS. 

As a group, the eruptive or exanthematous fevers have many feat- 
ures in common. All have a period of incubation, are characterized 
by a fever of more or less intensity preceding the eruption, by an 
eruption which is peculiar to each, occurring most commonly in 
childhood, rarely attacking the same person twice, very prone to 
occasion serious sequelae, and are contagious. Their origin is as yet 
undetermined. 



SCARLET FEVER. 

Synonym. Scarlatina, from the (old) Italian scarlattina, scarlatto 
(red). 

Definition. An acute, self-limited, contagious, infectious disease, 
usually of childhood ; characterized by high temperature, rapid pulse, 
a diffused scarlet eruption, terminating with desquamation, inflam- 
mation of the mouth and throat, and frequently more or less grave 
nervous phenomena. Serious sequelae frequently follow an attack. 
One attack confers immunity from the disease. 

Pathological Anatomy. An acute inflammation of the skin, 
with exudation — a true Dermatitis. A granular change in all the 
glandular structures, most marked in the Peyerian glands, although 
also occurring in the stomach and kidneys. Streptococci are usually 
found in abundance in the glands and areas of suppuration. 

Cause. A specific poison, maintaining its vitality for a long time. 
Highly contagious, the contagion residing chiefly in the desquamated 
epidermis. Klebs' micrococci, the " monas scarlatinosum," may 
prove to be the poison. Incubation short, one to seven days. 

Varieties. Scarlatina simplex, scarlatina anginosa, and scar- 
latina ?naligna. 

Symptoms. A mild attack is a very trivial affection, but in its 
severest form there are few diseases more malignant. 

Onset sudden with a decided c/zilland vomiting (in infants, convul- 



52 PRACTICE OF MEDICINE. 

sions), pain in the throat followed by high fever, soon reaching 105 ; 
a rapid pulse, no to 140, being frequent. At the end of twenty-four 
hours a bright scarlet rash appears on the neck and chest, spreading 
over the entire body within a few hours; the eruption is not raised, 
there is no intervening healthy skin, and scattered irregularly are 
points of a darker hue. With the appearance of the eruption occurs 
burning heat of surface, pain in the throat, and difficulty in deglu- 
tition, the throat on inspection presenting the appearance of a catar- 
rhal inflammation. Tongue at first furred, later red, with prominent 
papillae — the "strawberry tongue." There also occurs headache, 
great restlessness, and in severe cases delirium. Diarrhoea quite 
common. 

On the fourth or fifth day the fever declines by lysis, the eruption 
fading, and on the sixth or eighth day desquamation begins, con- 
tinuing for ten days, two weeks, or longer, the convalescence being 
slow, the patient emaciated and pale. 

Scarlatina anginosa are cases like the above with the addition of 
great inflammation and swelling of Xhe pharynx, nose, palate, tonsils, 
and neighboring glands, the swollen glands pressing upon the sur- 
rounding parts, causing difficulty of breathi?ig and of deglutition. 
Frequently the enlarged glands suppurate, increasing the constitu- 
tional symptoms and the distress of the patient. 

Scarlatina maligna are cases with decided nervous phenomena, to 
wit : convulsions, delirium, and muscular twitching, the temperature 
reaching 107 to 1 io°, the pulse rapid, feeble, and irregular, the erup- 
tion delayed, of a purplish color, and in patches. 

Complications. Three conditions are always to be looked for 
in all cases of scarlet fever ; otitis, affections of the joints, and acute 
nephritis, each adding to the gravity of the attack. 

The association of diphtheria with scarlet fever adds to the severity 
of the attack. The engrafting of these two diseases on the same 
individual is not an infrequent occurrence. 

Sequelae. Chronic sore throat; conjunctivitis ; otorrhcea; chronic 
diarrhoea ; subacute rheumatism ; chorea ; endocarditis ; pericarditis ; 
pleuritis; acute Bright' s disease, and cutaneous dropsy. 

Diagnosis. A typical case should cause no difficulty ; the high 
fever, rapid pulse, sore throat, and early scarlet eruption, followed by 
desquamation, should leave no doubt. 

Measles : the above symptoms are absent, and catarrhal symptoms 



FEVERS. 53 

present, the later appearance of the eruption and the difference in 
its character. 

Small-pox : eruption on the third day in spots, changing to pustules 
with secondary fever. 

Dengue or break-bone fever : absence of the above typical symp- 
toms, and presence of severe pains in the bones. 

Diphtheria : gradual invasion, great prostration, and no eruption, 
but the frequent complication of scarlatina and diphtheria must be 
remembered. 

Meningitis may be suspected from the symptoms of scarlatina 
maligna ; the epidemic influence, eruption, and rapid pulse are points 
of difference. 

Prognosis. Depends upon the character of the attack and the 
association of complications. Acute nephritis, endo- and pericarditis, 
and pleuritis add to the gravity. The prognosis is more grave, how- 
ever, from the association of diphtheria, the inflamed naso-pharynx 
presenting fertile soil for the ravages of that grave malady. Never 
can be positive of the result. Mortality ranges from ten to twenty- 
five per cent. 

Treatment. As with other eruptive fevers, so with scarlatina, 
there are no specific remedies by means of which it can be arrested 
or controlled. Symptomatic treatment judiciously applied, however, 
may afford relief and diminish the fatality. 

The indications are for rest in bed, good ventilation, isolation, dis- 
infection, cooling drinks, action upon the skin, and light nourishment. 

For a case of scarlatina simplex small doses of hydrargyri chloridi 
mite, sodii bicarbonatis, and pulvis ipecac, every two or three hours 
until thorough movement of the bowels occurs, will favorably influence 
the fever and rapid pulse and general distress. 

For cases with high/ever and rapidity of pulse, aconitum, digitalis, 
quinines sulphas; or, antifebrin, gr. j-ij (0.065-0.13 Gm.), every couple 
of hours, or phenacetin, gr. j-ij (0.065-0.13 Gm.), every two or three 
hours, with cool sponging, cold bath, douche, or pack. When, how- 
ever, the temperature reaches 102. 5 , at once use full bath at 90 F., 
for eight to ten minutes, then dry child quickly, wrap in blanket and 
put to bed, repeating bath if temperature and nervous phenomena 
are marked. 

If the surface be pale, the circulation feeble, and the eruption tardy 
in appearing, benefit will follow the administration of tinclura digi- 



54 PRACTICE OF MEDICINE. 

talis or tinctura belladonna, TT\j-v (0.06-0.3 Cc), according to age, 
and a hot bath or pack. 

With the appearance of the eruption anoint the entire body, save 
the head, with — 

R. Eucalyptol, f^j 4. Cc. 

Ung. petrolei, ^j 30. Gm. M. 

The inunction acts beneficially in many ways. It reduces the fever 
by soothing the cutaneous burning and irritation ; later on, when 
desquamation occurs, it limits the source of further infection by pre- 
venting the diffusion of the otherwise dry scales in the air ; and, finally, 
it protects the surface from the influences of sudden changes of 
temperature, thus to a great extent avoiding the danger of nephritis. 

For scarlatina anginosa, the internal use of the following combina- 
tion is valuable as a blood tonic and throat astringent : 

R. Tinctune ferri chlor., f^ij 8. Cc. 

Glycerini, f^j 30. Cc. 

Aquae, q. s. ad f^ij ad 60. Cc. M. 

Sic — One-half to one teaspoonful every two hours, undiluted, according 
to the age. 

Externally, ice or cold compresses, unless they cause chilliness, 
if so, heat. Astringent gargles and small pellets of ice dissolved in 
the mouth are of use. The throat and nasal cavities are kept clean 
and the breathing relieved by the use of Dobell's solution used with 
a hand atomizer every hour. The formula is : 

R. Acid, carbolici, f^iss 6, Cc. 

Sodii biboracis, 

Sodii bicarb., aa gij 8. Gm. 

Glycerini, f^ij 60. Cc. 

Aqua?, q. s. ad Oij ad 950. Cc. M. 

The use of this solution proves grateful to the patient, relieving the 
breathing through the nose by loosening the tenacious secretions. An 
excellent gargle for those old enough to properly use one is : 

R. Thymol, gr. iv .26 Gm. 

Glycerini, f5j 30. Cc. 

Aq. de.-^t. , 13 j 30. Cc M. 

SlG. — A throat wash. If necessary, dilute further. 



FEVERS. 55 

An excellent mouth and throat cleanser as well as gargle is aqua 
hydrogenii dioxidi, full strength or diluted. 

For scarlatina maligna, in addition io ferrum and quinince sulphas, 
the chief reliance must be on alcoholic stimulants, guiding the amount 
by their effects. In children, wine-whey, milk-punch, and egg-nog 
are eligible for the administration of stimulants and nourishment. 

Convulsions, or only great restlessness and muscular twitchings, are 
the result of the high grade of fever, and call for prompt treatment. 
Experience in such cases is against the group of antipyretic drugs, 
as not meeting the indication promptly enough. The cold wet pack 
or the cold bath with cold affusion or the ice cap are the most efficient 
and rapid means of reducing the temperature and relieving the 
nervous disturbances. 

Prof. Da Costa advocates the administration of ammonii carbonas, 
in small doses at frequent intervals, to prevent the liability of heart- 
clot, and for its salutary influence over the disease. 

It is claimed that a characteristic micrococci is found in the blood, 
and that, consequently, the disease can be favorably influenced by 
acidum carbolicum, thymol, or acidum boricum ; an eligible way of 
administering acidum carbolicum is the syr. ammonia phenatis 
(Declat), fgss-j (2-4 Cc), four to six times daily. 

There can be no doubt but that the complications and sequelae 
attending scarlet fever constitute the principal dangers of the dis- 
ease. 

If diphtheria develop, the combination of ferrum and hydrargyri 
chloridum corrosivum with free alcoholic stimulation are the indica- 
tions. 

Acute nephritis is so commonly associated with, or follows the 
decline of scarlatina that it is a prudent practice to examine the 
urine daily. If albumin appear, add to the ferrum, tinctura ca?i- 
tharidis in minute doses, and dropsy and uraemic symptoms may be 
prevented. If, however, true scarlatinal nephritis does develop, the 
following mixture of Hughes-Bennett, with saline purgatives and 
either a hot bath or the hot-air bath twice or oftener daily, will be 
followed by improvement : 

R. Potassii acetat., 5?ij 8. Gm. 

Spts. aetheris nitrosi, f.^ ss I S- ^ c - 

Aquae, q. s. ad f 3 ij ad 60. Cc. M. 

Sig. — Teaspoonful every two hours, well diluted. 



56 PRACTICE OF MEDICINE. 

Or— 

R • Hydrargyri chlor. mite, 

Pulv. scillae, 

Pulv. digital., aa gr. X - /^ .016-032 Gm. M. 

Ft. pil. No. j. 

Sig. — One such pill every three or four hours. 

If uraemic convulsions occur, use the hot-air bath, cupping over 
the kidneys, hypodermic injections of pilocarpines nitras, the inhala- 
tion of chloroformum, or, may be, the rectal use of chloral hydrate 
with or without potassii bromidum. Uraemic symptoms are often re- 
markably controlled by full doses of sodii benzoas. The elimination 
of the poison producing the convulsions is assisted by the high bowel 
enema of the normal salt solution. 

For scarlatinal rheumatism the use of ferrum alternately with the 
following : 

R . Ammonii salicyl., ^ij 8. Gm. 

Elix. simplicis, f.^ ss l S- Cc. 

Syr. simplicis, f 5j 30. Cc. 

Tinct. card, co., fj ss J 5- Cc. M. 

SlG. — Teaspoonful, diluted, four times daily. 

For inflammation of the middle ear it is much better to puncture 
the drum membrane than to allow its ulceration ; insufflations of 
acidum boricum and the internal use of ammonii chloridum. 

For the various other sequelcz the treatment is the same as if they 
occurred primarily, plus tonics. 

The disease being contagious, every means should be taken to 
prevent its spread — to wit, isolation, cleanliness, disinfection, and 
fumigation. 

Small doses of quinina, in those exposed, is said to prevent or 
modify the severity of an attack, but no true prophylactic is known. 

. J 

MEASLES. 

Synonyms. Morbilli ; rubeola. 

Definition. An acute epidemic and contagious disease ; charac- 
terized by catarrhal symptoms, referable to the naso broncho-pul- 
monary mucous membrane, fever, and a crimson mottled, papular, 
eruption which terminates by desquamation. 



FEVERS. 57 

Cause. A specific micro-organism, with a special susceptibility 
for childhood. Contagious by contact, and can be communicated by 
inoculation. One attack, as a rule, protects from a second. Incuba- 
tion, ten to fourteen days. 

Pathological Anatomy. There are no special anatomical 
characters exclusive of the eruption, which is considered among the 
symptoms of the disease. 

Symptoms. Onset gradual, following a chill or with irregular 
chills, fever, the temperature rising to ioi° or 102 , muscular soreness, 
headache, and intense nasal, pharyngeal, and laryngeal catarrh. 
The eyes are reddened and suffused and tears flow over upon the 
face. The throat is reddened and swollen. On the evening of the 
second day a decided remission takes place in the fever, the catarrh 
continuing ; on the fourth day occurs an eruption of a crimson color 
on the face, soon spreading over the body, in the form of papules and 
blotches, which coalesce into irregular circles or crescents, with islands 
of white skin between, and with the appearance of the eruption the 
fever returns, the catarrh is aggravated, but the character of the dis- 
charge, instead of remaining clear and watery, becomes turbid, thick, 
and yellowish, and extends to the bronchial mucous membrane. 
About the ninth day (the fourth of the eruption), the eruption fades, 
the symptoms abate, and slight desquamation occurs. Some cough 
and catarrh may remain for a long period. 

Black measles, sometimes called hemorrhagic rubeola, or camp 
measles, is a variety occurring in camps and jails, in which occur 
dangerous chest symptoms, and black spots or rjetechiye from deteri- 
orated blood, and severe prostration. 

Koplik, in 1896, described a peculiar eruption found on the buccal 
mucous membrane (lining lips and cheeks only), consisting " of small, 
irregular spots of a bright red color ; in the center of each spot a 
most minute bluish-white speck. These minute bluish-white specks 
in the center of a reddish spot are pathognomonic of beginning 
measles." I have almost invariably found them at the onset 
of the chill and catarrhal symptoms, and been able to make a 
diagnosis before the characteristic eruption of measles appeared. 
These tiny spots fade with the appearance of the mottling of the 
skin. 

Rather common complications are tonsillitis, and lobar ox catarrhal 
pneumonia. 
6 



58 PRACTICE OF MEDICINE. 

Sequelae. In those of strumous diathesis, scrofula or tuberculosis 
may develop. 

Diagnosis. A typical case begins gradually, with chilliness, 
nasal catarrh, watery eye, and fever, which decline before the erup- 
tion, rising afterward; the eruption is crescentic in shape and of a 
crimson color, beginning on face, followed by desquamation. If ex- 
perience shall determine that the eruption mentioned as occurring on 
the buccal mucous membrane at the onset is invariable, the diagnosis 
will be readily determined. 

Scarlet fever : absence of catarrh, and earlier appearance and dif- 
ferent character of the eruption, with high fever and rapid pulse. 

Prognosis. As a rule, a perfect recovery. If tuberculosis de- 
velop, the prognosis is bad. Black measles, the majority succumb. 

Treatment. No specific. Mild cases require no medicine, sim- 
ply regulating the diet and bowels, and cool sponging; the indica- 
tions are to render the patient as comfortable as possible, the disease 
pursuing a favorable course without therapeutical interference. 

If the febrile reaction is high, the following soon controls it : 

K . Tinct. aconiti rad., W\,ss-j .03-.C6 Cc. 

Spts. retheris nitrosi, ttlx-xv .6-1. Cc. 

Liquor potassii citrat., . . . . adf^j 4. Cc. 
Every two hours. 

For the pruritus of the eruption, the local use of oils and fats, par- 
ticularly of eucalyptol, f^ss-j (2-4 Cc), ung. petrolei, 3J (30 Gm.). 
For catarrhal symptoms, inunction of the nose, neck, and chest 
with camphorated oil and small doses of pulv. ipecac, et opii at bed- 
time ; if the catarrh extends to the bronchial mucous membrane, 
expectorants. 

During convalescence, for the strumous, protect from exposure, 
and administer oleum morrhua with syr. ferri iodidi. For black 
measles, bold stimulation, and ferrwn and quinina. 



RUBELLA. 

Synonyms. Rotheln ; epidemic roseola ; German measles ; 
French measles; false measles. 
Definition. An acute, self-limited, contagious disease; charac- 



FEVERS. 59 

terized by mild fever, suffused eyes, cough and sore throat, enlarge- 
ment of the lymphatic glands of the neck, and a rose-colored eruption, 
in patches of irregular size and shape, appearing on the first day. 

Many so-called second attacks of measles and scarlet fever are 
attacks of rubella (Tyson). 

Cause. Propagated by contagion. That a peculiar germ exists 
is probable, but thus far it has not been isolated. Incubation from 
one to three weeks. 

Rubella bears the same relation to measles that chicken-pox does to 
small-pox (Tyson). 

Symptoms. Onset sudden, with mild fever, suffused eyes, with 
little or no coryza, sore throat, and enlargement of the cervical glands, 
not limited to those about the angle of the jaw, as in scarlatina. 
Any time from the first to the fourth day appear rose-colored spots, 
size of a pin-head, slightly elevated, which coalescing, form irregular 
shaped and sized patches, with intervening healthy skin, fading on 
the upper part of the body while just appearing on the lower. Symp- 
toms all terminate within a week by lysis, the patient showing no ill 
effects from the attack. 

Diagnosis. From scarlet fever, by absence of high fever, the 
rapid pulse, the color and character of the eruption, and the sequelae. 

From measles, by absence of intense catarrhal symptoms, the late 
appearance of eruption, and its crescentic shape. 

Prognosis. Most favorable. 

Treatment. Mild laxatives and restricted diet. If fever high, 
saline mixture. For itching of skin, sponging with vinegar and water, 
or inunction with vaseline. 



SMALL-POX. 

Synonym. Variola. 

Definition. An acute epidemic and contagious disease ; charac- 
terized by severe lumbar pains, vomiting, and an initial fever, lasting 
from three to four days, followed by an eruption, at first papular, then 
vesicular, and afterward pustular ; the development of the pustule 
being accompanied by a secondary fever, during the presence of 
which grave complications are prone to occur. 

Causes. A specific poison whose nature is unknown, maintaining 



CO PRACTICE OF MEDICINE. 

its contagious vitality for a long period. " There is no contagion so 
strong and sure as that of small-pox, and none that operates at so 
great a distance" (Watson). There is no period, from the initial 
fever to the final desquamation, when the disease is not contagious, 
although the stage of suppuration is the most virulent. One attack, 
as a rule, protects from a second. Vaccination has a positive pro- 
tective influence from the disease, an extensive observation having 
fully proven that in proportion to the efficiency of vaccination is the 
rarity and mildness of variola. Incubation, fourteen to sixteen days. 

Pathological Anatomy. A granular and fatty degeneration 
occurs in the liver, spleen, kidneys, and heart. The pustules are 
found in the larynx, trachea, bronchial tubes, and on the pleura. 

Varieties. Discrete ; confluent ; malignant ; varioloid or modi- 
fied small-pox. 

Symptoms. Discrete for?n. Onset sudden, with a viole7it chill, 
vomiting, and agonizing pains in the back, shooting down the limbs; 
fever, in short time rising to 103 or 104 F. ; full, strong, and rapid 
pulse, ranging from 100 to 130; the face red, eyes injected, intense 
headache, and sleeplessness; prostration great from the very onset. 
Delirium and convulsions occur at times. During the third day the 
characteristic eruption makes its appearance, first on the forehead 
and lips, consisting of coarse red spots. With the appearance of the 
eruption all the marked symptoms of the fever abate, the patient feel- 
ing quite comfortable. On thefflh day of the disease the spots be- 
come papules ; on the sixth day, transformed into vesicles, which are 
soon umbilicatcd ; on the eighth day the vesicles change to pustules ; 
on the ninth day the pustules are entirely purulent, and each sur- 
rounded with a broad red band — the halo or areola, the face becom- 
ing swollen and the features distorted ; on the eleventh day, pus 
oozes from the pustules, and drying, -forms the scab, or crust, which, 
on the seventeenth to twenty-first day, drops off, leaving a red, glisten- 
ing depression or pit, soon changing into a white cicatrix. With the 
formation of the pustules {eighth day) severe rigors and fever set in, 
and a characteristic odor is emitted, all the original symptoms return- 
ing. This secondary fever, the fever of suppuration, is the most critical 
period of the disease, and is generally attended with violent delirium. 
In favorable cases the secondary fever subsides after three or four 
days, and convalescence is established. 

Confluent small-pox differs from the discrete in the greater severity 



FEVERS. 61 

of all the symptoms and the marked prostration of the patient, the 
eruption appearing during the second day, the pustules coalescing 
into large patches, causing great distortion of the features. 

Malignant small pox is characterized by the greater intensity and 
the irregularity of the symptoms, death resulting before the character- 
istic eruption appears, by convulsions or coma. In these cases hem- 
orrhages are frequent and petechias are observed. 

Varioloid, or modified small-pox, is the form modified by previous 
vaccination, or by a former attack of small-pox. Its course is shorter 
and milder than the other forms, the eruption appearing a day later, 
and is not attended with secondary fever. 

During some epidemics two other eruptions are observed, appear- 
ing on the second day, one petechial, in the form of a fine macular or 
spotted eruption on the abdomen and legs, "Simon's triangle" ; the 
other an erythematous eruption on the sides and inner surface of the 
legs. Both disappear within forty-eight hours. 

Complications. During the course of the secondary fever there 
is a great tendency to grave inflammations, such as pleurilis, pneu- 
monitis, and dysentery. During convalescence, boils and abscesses on 
the skin are frequent. 

Diagnosis. Cannot be confounded with any other disease if it 
has typical symptoms, such as chill, vomiting, pains in back and legs, 
high fever and pulse, all declining on third day, when the erup- 
tion appears, first spots, then papules, then vesicles, finally pus- 
tules, drying and forming crusts, and with the marked secondary 
fever. 

Prognosis. Depends upon the variety of the attack, the age of 
the patient, and whether vaccinated or not. Discrete, mortality four 
per cent. ; confluent, fifty per cent. ; malignant, all perish. Under five 
years and over forty years of age, fifty per cent. die. 

Treatment. If the patient is seen early, vaccination should be 
performed at once; it may modify the attack. In the absence of a 
specific, the treatment is entirely symptomatic. Rest in bed, good 
ventilation, the temperature kept at 65 F., avoiding draughts. For 
the initial fever, full pulse, and pains, phenacetin, gr. x (0.65 Cm.), 
or antifbrin, gr. v (0.32 Gm.), or acetanilidum, gr. v-x (0.32-0.65 
Gm.), or, what is still better, as more soluble, a7itipyrin, gr. x 
(0.65 Gm.), repeated p. r. n., are of great service, rendering the 
symptoms more endurable. Depressing doses must be avoided. 



62 PRACTICE OF MEDICINE. 

Fur the headache, ice bags to the head and a mustard sinapism to 
the nape of the neck. 

For sleeplessness and restlessness or early delirium, full doses of 
potassii bromidum, chloral, or trional. 

F 'or secondary fever the best remedy is quinina, gr. v (0.32 Gm.) 
every three hours, and for cerebral excitement of this period, either 
full doses of potassii bromidum, by stomach, or the following by 
rectum : 

R . Chloral, . . gr. xx 1.3 Gm. 

Mucil. acacise, fgij 8. Cc. 

Inf. digitalis, ad q. s. f^j ad 30. Cc. 

p. r. n. 

The secondary fever being pyaemic in character, the depression 
should be anticipated by large doses of tinctura ferri chloridi and 
judicious stimulation, brandy in tablespoonful (15 Cc.) doses being 
most efficient. 

From the onset, milk, eggs, animal broth, oysters, and beef-juice 
should be administered every three hours. Ice is always grateful and 
should be given freely, and if pustules appear in the mouth, ice 
should be held in the mouth as long as possible, and washes of 
potassii chloras or acidum carbolicum employed. 

The disease being contagious, isolation, ventilation, cleanliness, 
and disinfection are imperative. 

To prevent pitting, keep patient in a dark room, well ventilated. 
Masks of some unctuous material, thoroughly applied to exclude the 
air, have a beneficial effect. Success is claimed by a number of ob- 
servers from the use of collodium applied once or twice daily. Cold 
water dressings constantly to face and hands are beneficial, besides 
allaying heat, pain, and swelling. Hot water can be used if more 
grateful. The water dressings should be made antiseptic with subli- 
mate solutions, 1 : 5000 or 1 : 10,000; fchihyol,five to twenty percent, 
solution, painted over the pustules several times a day, is recom- 
mended to hasten the drying up, check extensive suppuration, and 
prevent pitting. If water dressing seem undesirable, anoint the body 
with eucalyptol, f 3 j (4 Cc), rubbed into unguentian petrolei, %) 
(30 Cc), or acid, carbolic, gr. x (0.65 Gm.) to an ounce (30 Cc.) of 
vaselin or lanolin. 



FEVERS. 63 

VACCINATION. 

Synonyms. Vaccinia ; cow-pox. 

Definition. Inoculation with the matter of vaccinia or cow-pox 
— bovine virus. The person properly vaccinated is, as a rule, pro- 
tected from an attack of small-pox, and especially from a severe or 
fatal attack. 

Vaccination should be performed at least twice in every individual, 
during infancy and at puberty ; and it is safer to have it again per- 
formed if special exposure be liable or has occurred. 

In practising vaccination the skin should be rapidly scraped until 
the true skin is reached and is ready to bleed, the lymph being then 
brushed over the abraded surface ; or, instead, make three or four 
horizontal and transverse cuts, about four lines long, and rub the 
virus over them ; a little blood, but not much bleeding, should result. 

Symptoms. If the vaccination "takes," on the third day a 
Papule appears ; on the sixth day a vesicle has formed, with a central 
depression ; on the eighth day a pustule, fully formed and distended 
with lymph, with a reddish areola, which becomes very wide. The 
areola begins to fade on the tenth day, the pustule begins to dry, and 
by the fourteenth day a brown mahogany scab or crust has formed, 
which is detached about the twenty-third day. The cicatrix is circu- 
lar, depressed, radiated, and foveated, becoming, after a time, paler 
than the surrounding integument. 

During the course of a vaccination more or less constitutional dis- 
turbance occurs, especially in children. 

Eczematous and papular eruptions often develop in strumous chil- 
dren, for which the virus is unjustly held responsible. 



VARICELLA. 

Synonym. Chicken-pox. 

Definition. A mild, slightly contagious, febrile affection ; char- 
acterized by a moderate fever, and the appearance of a vesicular 
eruption, drying up and falling off in from three to five days. 

Cause. A peculiar poison ; attacking only children ; occurring 
sporadically and as an epidemic. 

Symptoms. Moderate fever, thirst, anorexia, and constipation, 



64 PRACTICE OF MEDICINE. 

followed by the eruption of vesicles, which rapidly dry, and within 
the week drop off, leaving a slight///. Pustules almost never occur. 
Symptoms are so slight that, were it not for the vesicles, the affection 
would be often overlooked. The eruption appears on the body and 
extremities, very rarely on the forehead and in the mouth. 

Prognosis. Most favorable. 

Treatment. Entirely symptomatic. If vesicles on the face, 
efforts may be used to prevent pitting. 



ERYSIPELAS. 

Synonyms. Erysipelatous dermatitis ; the rose ; St. Anthony's 
fire. 

Definition. An acute, specific, infectious disease ; characterized 
by more or less severe febrile reaction, and a peculiar inflammation 
of the skin generally of the neck and face. This inflammation exhibits 
a marked tendency to spread, to induce serous infiltration and suppu- 
ration of the areolar tissue, and to affect the lymphatic vessels and 
glands. 

Cause. A specific virus ; a micrococcus, the Streptococcus erysipe- 
losus. Feebly contagious. One attack predisposes to another. The 
etiology of idiopathic (medical) and traumatic (surgical) erysipelas 
are identical. Incubation, from two to seven days. 

Pathological Anatomy. Erysipelas is a simple inflammation — 
a dermatitis. The visceral changes, if any occur, are of a septic 
character. Infarcts occur in the lungs, spleen, and kidneys. Septic 
endocarditis and pericarditis and pleuritis are found post-mortem. 
Acute nephritis may occur. 

Symptoms. Onset sudden ; a chill, followed by fever, which 
soon reaches 104 to 105 , frequent pulse, 100 to 130, coated tongue, 
nausea and vomiting, severe pains in the limbs, with epistaxis in 
adults and convulsions in children, and often diarrhoea. There is 
usually more or less pharyngitis, and even tonsillitis, causing painful 
deglutition. 

Delirium is frequent, and in those of alcoholic habits it resembles 
delirium tremens. 

The eruption soon follows the chill, beginning in red spots, which 
rapidly coalesce and spread ; a sense of heat, tension, and tingling is 
caused by the great oedema, which presents a tense, shiny appearance, 



FEVERS. 65 

the swelling being so great at times as to close the eyes and distort 
the features. In many cases small vesicles develop, which may 
coalesce, forming blebs of considerable size, containing a clear yellow 
serum. After five or six days the eruption begins to subside, the 
symptoms abate, the part affected remaining tender, and there 
occurs moderate desquamation. 

During the height of the attack albumin appears in the urine, so 
that the possibility of urcemic symptoms must be remembered. 

When extensive infiltration into the areolar tissue occurs, the swelling 
and tension become greater, and it is termed p hlegmonous erysipelas. 

When the eruption spreads to different portions of the body, it is 
termed erysipelas ambulans. Da Costa cites a case of migratory, 
wandering, or ambulans erysipelas, beginning on cheek and spread- 
ing from part to part until the entire body was affected, lasting three 
months and recovering. 

Complications. Thrombosis of the cerebral capillaries or sinuses, 
or, as it is sometimes called, " erysipelas of the brain," is explained 
by the intimate anatomical connection of the facial vein with the 
pterygoid plexus and cavernous sinus. 

(Edematous laryngitis, from extension to the larynx. 

Pneumonia, pleurisy, and meningitis are frequent complications. 

Diagnosis. Not difficult. The fever, early spreading eruption, 
with burning, swelling, tension, and tingling, and albuminous urine, 
distinguish it from the other eruptive fevers and erythema. 

Prognosis. Usually favorable. Unfavorable if it attack drunk- 
ards ; if it become gangrenous ; if thrombosis of sinuses occur, or if 
it extend to the larynx. 

The convalescence, even from the mildest attack, is slow, the 
patient continuing weak and anaemic for several weeks. 

Treatment. Mildest cases only require a laxative, nourishing 
diet, and locally vaseline or bismuth oleate, to modify the heat and 
burning. 

Professor Da Costa strongly urges the use of free purgation before 
the use of the remedies usually administered. Excellent results fol- 
low the use of: 

R . Hydrarg. chlor. mitis, gr. j .065 Gm. 

Sodii bicarb., gr. ij .13 Gm. M. 

Ft. chart. 

SlG. — One every two hours until four, followed by a saline. 



66 PRACTICE OF MEDICINE. 

According to Reynolds, aconitum will cut short a sthenic attack. 
He administers tr^ss-j (0.03-0.06 Cc.) every fifteen minutes for the 
first two hours ; then in hourly doses, until the surface is moist and 
the temperature lowered. The aconite can be used with the above 
powder. The author corroborates this plan from a personal experi- 
ence. Watch the kidneys. 

In severe cases, after bowel action, tinctura ferri chlor., n^x-xx 
(0.6-1.3 Cc.) every third hour, well diluted. Also quinince sulphas, 
gr. ij (0.13 Gm.) every third hour. Ext. belladonna, gr. % (0.016 
Gm.), added, with benefit. The diet from the onset should be of the 
most nourishing character, and administered at regular intervals. 

Professor Da Costa reports excellent results in cases with rapid 
spreading tendency, from the use of pilocarpifice hydrochloras, gr. 
l /e (0.011 Gm.), hypodermically, or ext. pilocarpi fluidum, tt^xx-xxx 
(1.3-2 Cc), every two hours. Good results are obtained in a fair 
number of cases from potassiiiodidum. I have obtained good results 
in rapidly spreading cases from injection of 10 Cc. of the anti-strep- 
tococcus serum. 

Cerebral symptoms, stimulants, opium, and chloral, with ice cap. 

Extension to throat, argenti nitras, brushed over parts. If symp- 
toms of cedema of the glottis develop, tracheoto?ny is indicated. 

Locally, soothing applications are indicated — to wit : Vaseline, ung. 
zinci oxidi, ol. oliva cum glycerin, bismuth oleat., or u?igt. hydrar- 
gyria)!. Excellent results are obtained by the use of ichihyol, gr. 
xx-xxx (1.3-2 Gm.), lanolin, %) (30 Gm.), applied on gauze; if the 
face be the seat of disease, cover with a mask of gauze spread with 
the ointment. 

The following solution painted over the inflamed area and beyond, 
every two or three hours, sometimes seems beneficial : 

H- Acid, carbolic, f 3 ss 15. Cc. 

Olei terebinthince, f Sj 30. Cc. 

Tinct. iodi, f^j 30. Cc. 

Alcoholis, fjjj 30. Cc. 

Glycerini, fgss 15. Cc. M. 

Ft. solutio. 

Keeping the inflamed parts bathed with a twenty per centum solu- 
tion of glyceriium boroglycerini, occasionally wetting the cloths with 
solution of hydrogen peroxid, is cooling, or gauze spread with euca- 
lyptol ointment, f^j (4 Cc.) to an ounce of lanolin, is soothing. 



FEVERS. 07 

In the phlegmonous variety, argenti nitras, gr. xx (1.3 Gm.), spts. 
cetheris nitrosi, f 3 ij (8 Cc), brushed over and beyond the affected 
part, with the internal use of large doses of qicinina,ferrum, and 
stimulants. 



DENGUE. 

Synonyms. Break-bone fever ; neuralgic fever ; dandy fever. 

The word dengue is pronounced dangay. 

Definition. An acute, epidemic, febrile disease, consisting of two 
paroxysms of fever with an intermission. The first paroxysm is char- 
acterized by high fever, distressing pains in the joints and muscles, 
and a peculiar eruption ; the second paroxysm is characterized by 
a milder fever, an eruption of different character, attended with 
intense itching, by some recurrence of the joint pains, and by 
debility. 

Cause. Unknown ; but it is evident that a peculiar condition of 
the atmosphere has some influence in its development. Incubation, 
from two to six days. 

Symptoms. Onset sudden— -fever, 103 to 105 , intense headache, 
burning pains in the temples, backache, severe aching and swelling 
of the joints and stiffness of muscles, nausea, vomiting, constipation, 
and the appearance of a rash, resembling scarlatina, from which the 
disease has been mistaken for scarlatinal rheumatism. After some 
hours to two or three days a distinct intermission of one or two days' 
duration obtains. 

The onset of the second paroxysm is also sudden, but the symp- 
toms are much less severe, although the patient is greatly debilitated ; 
it is at this time that the characteristic eruption appears, being either 
erythematous or rubeolous, and attended with intense itching, remain- 
ing for about two days, when desquamation occurs and convalescence 
is established, but is prolonged by the great debility of tha patient. 
Average duration of the disease eight days. Relapses are common. 

Diagnosis. Most apt to be mistaken for acute articular rheuma- 
tism, especially during the first paroxysm, but the course of the dis- 
ease and the epidemic influence should prevent such an error. 

The eruption might mislead for scarlet fever or measles, were it not 
for the severe joint and muscular pains. 

On the first appearance of the pandemic of La Grippe in 1889 the 



68 PRACTICE OF MEDICINE. 

similarity of the early myalgic symptoms with those of dengue was 
particularly noticeable. 

Prognosis. Favorable. 

Treatment. No specific. Entirely symptomatic. 

At the onset, fate, purgation and diaphoresis. 

For the fever, quinines sulphas, gr. v (0.32 Gm.) every five hours, 
or antipyrin, gr. x-xx (0.65-1.3 Gm.), repeated p. r. n. 

For the pains, opium or phenacetin. 

For the itching, a lotion of acidum carbolicujn. 



DISEASES OF THE MOUTH. 



CATARRHAL STOMATITIS. 

Synonyms. Simple stomatitis ; erythematous stomatitis ; catarrh 
of the mouth. 

Definition. An acute catarrhal inflammation of the whole or a 
portion of the mucous membrane of the mouth and tongue, charac- 
terized by pain, redness, swelling, and disordered secretion. Most 
common in infants and children. Chronic stomatitis occurs mostly in 
adults, the result of alcoholic or tobacco excesses. 

Causes. Introduction of hot and irritating substances into the 
mouth ; difficult dentition ; secondary to disorders of the stomach, to 
measles, scarlet fever, diphtheria, and variola. 

Pathological Anatomy. The buccal mucous membrane and 
tongue have a dark red appearance, are much swollen, the tongue 
often appearing as if too broad to lie between the teeth, the sides 
showing the impressions of the teeth ; the secretions are at first less- 
ened, afterward increased, a turbid mucus covering the cheeks, gums, 
and tongue. 

Symptoms. Oral catarrh begins with the ordinary signs of 
inflammation, burning, smarting pain, and tension in the mouth, in 
those old enough to describe their suffering. Very young children 



DISEASES OF THE MOUTH. G9 

refuse to nurse or allow their mouth to be touched, taking hold of the 
nipple, giving one or two pulls and suddenly letting go and beginning 
to cry, have s tight fever, disordered stomach, are fretful and sleep- 
less, craving cooling drinks. 

The sense of taste is blunted, and there is usually an unpleasant, 
bitter taste in the mouth. 

If the catarrh becomes chronic, the breath has a fetid odor and the 
tongue is coated in the morning, the taste is disordered, and there is 
generally more or less depression of spirits. 

Diagnosis. If the buccal cavity be examined, the condition is 
readily discerned. 

Prognosis. Recovery is the rule for the acute variety. 

The chronic cases are usually due to the use of tobacco or alcohol, 
and are only modified by the absolute withdrawal of the exciting cause. 

Treatment. The most important point in the treatment is the 
removal of the exciting cause, attention to the secretions and diet, 
and gently mopping out the mouth at frequent intervals with a soft 
wad of absorbent cotton and cold or iced water, infusum coptis, or 
diluted Dobell's solution (see Scarlet Fever), or the following : 

& . Sodii boratis, gr. xc 6. Gm. 

Aquae destillat. , f.^iss 45- Cc. 

Mel. rosae, f^iss 45- Cc. 

In severe or aggravated cases a dilute solution, argentum nitras, 
gr. ij-v (0.13-0.32 Gm.), aquae, fgj (30 Cc), should be applied. 



APHTHOUS STOMATITIS. 

Synonyms. Follicular stomatitis ; vesicular stomatitis ; croupous 
stomatitis. 

Definition. An acute inflammation of the follicles and mucous 
membrane of the mouth and tongue, characterized by a fibrinous or 
croupous exudation; the exudation first appearing in isolated spots 
{aphtha discrete), afterward coalescing, and forming large and irreg- 
ular sized patches {aphtha confluens), which rupture, leaving an 
ulcer, which slowly heals. 

Causes. A disease principally of childhood. Difficult dentition ; 
disorders of digestion ; uncleanliness, such as neglect to rinse the 



70 • PRACTICE OF MEDICINE. 

child's mouth after nursing ; a symptom of measles and diseases of 
the buccal cavity. 

Pathological Anatomy. Begins as a small, whitish papulo- 
vesicular elevation, semi-transparent, hard, and tender, with a distinct 
red zone about the base ; there may be as few as six or as many as 
twenty ; they may remain isolated (aphtha discrete) or coalesce 
(aphtha conflue?is) ; they are regarded as either a peculiar deposit or 
a local croupous exudation. After a day or two they rupture, leaving 
an irregular white or grayish ulcer, which slowly heals. The seat of 
the affection is the internal surface of the lips and cheeks, the gums, 
tongue, and roof of the mouth. 

Symptoms. The condition begins with redness of the mucous 
membrane of the mouth, followed rapidly by the spots or vesicles on 
the inner surfaces of the lips, the edges of the tongue, and the cheeks ; 
in infants the pai7i is so severe that the child refuses to nurse ; in 
older children, pain from talking, mastication, and deglutition ; saliva- 
tion is marked, the saliva dribbling from the mouth. There is slight 
feverishness, frelfubiess, and sleeplessness. Digestion is impaired, 
and quite commonly diarrhoea occurs. A disagreeable, penetrati7ig 
odor escapes from the buccal cavity. 

Diagnosis. Impossible to confound with any other affection if 
the buccal cavity is examined. 

Prognosis. Always favorable. 

Treatment. Removal of the exciting cause. Attention to the 
dietary and the secretions is paramount. If constipation occur, 
the use of a few powders of hydrargyri'chloridiwi mite, containing 
gr. j 1 ^ (0.005 Gm.), adding a small amount of sodii bicarbonas or small 
doses of pepsinum. Also small doses oiinfusiun coptis, which seems 
to have also a specific action in all forms of stomatitis and gastritis. 
Protracted cases require tonic doses of quinina sulphas. 

Locally, good results are obtained from strong solutions of potassii 
ch loras, infusum coptis, or touching the ulcers with arge?iti ' nitras . 



ULCERATIVE STOMATITIS. 

Synonyms. Diphtheritic stomatitis ; gingivitis ulcerosa. 
Definition. An acute diphtheritic inflammation of the mucous 
membrane of the mouth, continuing until extensive and unhealthy 



DISEASES OF THE MOUTH. 71 

ulcerations occur. It usually begins on the margin of the lower gums, 
and often extends to the lips, cheeks, or tongue. 

Causes. Usually seen in children only. Most frequently in the 
families of the poor, the result of unfavorable hygienic surroundings, 
personal uncleanliness, and poor food. Often seen in those reduced 
by severe acute disease. Perhaps contagious, as epidemics are not 
rare. Prevails in institutions, jails, and camps, in which the sanitary 
conditions are defective. 

Pathological Anatomy. The gums first appear congested, 
swollen, bleeding readily, and separated from the teeth ; soon a firmly 
adherent deposit in the form of patches appears, at first whitish, 
speedily becoming gray or even black, from disintegration, becoming 
soft and pulpy, the separated slough leaving irregular-shaped ulcers, 
with raised margins, from cedema of the surrounding tissue. They 
are not deep, and their surface is covered with a pulpy, yellowish 
substance. The morbid process usually extends to the inner side of 
the lips, cheeks, and to the tongue. 

Symptoms. Begins with swelling of the mucous membrane 
about the base of the teeth, followed with pain aggravated by 
mastication or deglutition ; food and drink must be of the bland- 
est character. The mouth is hot, the saliva dribbles away, mixed 
with blood and shreds of pulpy matter, the breath is fetid, the appe- 
tite, digestion, and bowels disordered. The patient is feverish, fretful, 
and sleepless. 

There is always enlargement and tenderness of the submaxillary 
glands. 

The affection is often associated with entero-colitis. 

Diagnosis. Apt to be confounded with gangrenous stomatitis, 
than which, however, there are less constitutional symptoms and a 
slower course of the malady. 

Prognosis. Favorable. If promptly and properly treated, the 
ulcerated surface heals rapidly, although quite commonly some teeth 
are lost. 

Treatment. The etiology of the affection must be borne in mind 
and remedied. Strict attention to the diet, to the secretions, and ab- 
solute cleanliness. 

Internally, the prompt use of potassii chloras, gr. j-v (0.065-0.32 
Gm.), alone or with infusum coptis, frequently repeated, often acts like 
a specific. The general health frequently calls for quininajtrruin, and 
stimulants. 



72 PRACTICE OF MEDICINE. 

Locally, a strong solution of potassii chloras, or keeping the ulcer 
covered with bismuth, or frequent applications of alumen exsiccatum 
are valuable. Cases which resist these remedies should have applied 
the following combination, proposed by the late Dr. Dewees : 

U. Cupri sulphat., gr. x .65 Gm. 

Pulv. cinchonoe opt., gr. cxx 8. Gm. 

Pulv. g. arab. , gr. Ix 4. Gm. 

Mel. commun., f^ij 8. Cc. 

Aquoefont., f^i'j 9°- Cc. 

Ft. sol. 

Sic — The ulceration to be touched twice daily with the point of a camel's 
hair pencil. 

If a spreading tendency develop, the application of argenti nitras 
dilutus, or a diluted solution of acidum nitricum, is indicated. 



THRUSH. 

Synonyms. Parasitic stomatitis ; muguet ; sprue ; white mouth. 

Definition. An inflammation of the mucous membrane of the 
mouth, associated with or caused by the growth of & parasitic plant, 
the o'idium albicans ; characterized by pain, disorders of digestion and 
of the bowels. 

Causes. The development of the thrush-fungus o'idium albicans, 
is promoted by all those conditions designated as unhygienic, by de- 
bilitated conditions of the general system, and by neglect to thor- 
oughly rinse the mouth after nursing or bottle-feeding. It is claimed 
that a catarrhal stomatitis is the soil upon which the fungus develops. 

The age is considered a predisposing cause, seldom being seen 
after two years of age. In adults, only toward the last stages of 
cancer or consumption. 

Pathological Anatomy. The mucous membrane of the mouth 
presents a dark red appearance in isolated patches, on which whitish 
points appear, which rapidly coalesce into large areas. They closely 
resemble curdled milk, from their soft consistency. These whitish 
points consist of epithelium and fat, in which are embedded the 
sj) >rules and filaments of the fungus. 

The deposit first appears about the angles of the mouth, soon 



DISEASES OF THE MOUTH. 73 

extending to all parts of the cavity, often to the pharynx and 
oesophagus. The mouth is usually swollen and tender, the breath 
often fetid. 

Symptoms. Pain, aggravated by nursing or mastication. The 
lips are swollen, the saliva is increased, the breath hot and some- 
what fetid. There is usually increased temperature. Diarrhcea is 
frequent, the stools green and sour, causing an erythema of the 
buttocks. 

Diagnosis. The curd-like appearance of the deposit, showing 
the presence of the fungus upon microscopical examination, will 
prevent error. Should not be confounded with aphthous stomatitis, 
in which ulcers, preceded by the formation of vesicles, are perfectly 

» distinctive. 
Prognosis. Favorable, unless occurs toward the termination of 
exhausting diseases. 

Treatment. Absolute cleanliness of the mouth is all-important. 
Internally, remedies should be directed to the removal of the dis- 
orders of the gastro-intestinal tract. 

Prompt relief has followed the use of sodii hyposulphitis saturat. 
iolut., TTiiij-x (0.18-0.6 Cc), every two or three hours, and the local 
application of the same solution. 

Locally, solutions of sodii boras often answer every indication, the 
best vehicle being glycerinum or infusum coptis, and not mel or sac- 
charum, a good formula being : 

$. Sodii boratis, gr. lx 4. Gm.. 

Glycerini, f^ij 8. Cc. 

Aquae, f ^ vj 24. Cc. 

Sic — Thoroughly applied four or five times daily, and continued for a week 
after the disappearance of the affection. 



GLOSSITIS. 

Definition. An inflammation of the parenchyma of the tongue ; 
haracterized by great swelling of the organ, with difficult mastica- 
on, deglutition, and vocalization. 

The affection may be either acute or chronic. 

Causes. The acute variety is usually the result of some direct 
citation to the tongue, such as direct injury, contact of boiling 
7 



74 PRACTICE OF MEDICINE. 

liquids, the action of acrid or corrosive substances, or the sting of the 
tongue by an insect, such as the bee or wasp. 

The chronic variety is generally circumscribed ; it may follow the 
acute ; be due to the sharp edges of the teeth, or the use of a tobacco 
pipe. 

Pathological Anatomy. Acute glossitis begins with intense 
hyperaemia, redness, and swelling of the organ ; the size often be- 
comes so great that the tongue is too large for the mouth, and thus 
protrudes between the teeth ; its surface is covered with a thick 
secretion, and it becomes of a pale or grayish color. The swelling 
may rapidly decline, or abscesses may form, which leave a more or 
less decided depressed cicatrix. 

Chronic glossitis occurs usually along the edges of the organ, the 
cicatricial changes being in circumscribed hard spots. If the entire 
tongue is affected with chronic inflammation, the action is superficial, 
and has been termed " psoriasis of the mouth." 

Symptoms. Acute glossitis begins rather abruptly with fever, 
increased pulse, restlessness, anxiety, enlargement of the tongue, a 
sensation of heat in the mouth, with pain, and increased flow of 
saliva. Mastication and deglutition become difficult if not impossible, 
the voice muffled, and dyspnoea decided. The glands at the angles of 
the jaws are enlarged, which, in turn, compress the vessels of the neck. 

When suppuration supervenes, the constitutional symptoms become 
severe and the oral symptoms are intensified. Death has occurred 
from suffocation in severe cases. 

Chronic glossitis presents fain as the chief symptom, aggravated 
by movements of the organ. 

Diagnosis. The rapid course of acute glossitis should prevent its 
being mistaken for any other affection. 

Chronic glossitis, if severe, might be mistaken for cancer of the 
tongue, although the slow and mild progress of the former contrasts 
strongly with the rapid, severe, and painful course of the latter, with 
its marked constitutional symptoms. 

Prognosis. Acute glossitis usually terminates in recovery within 
a week, although the danger of suffocation must always be remem- 
bered. 

Chronic glossitis is an incurable malady in the majority of in- 
stances. 

Treatment. For acute glossitis prompt measures are demanded. 



DISEASES OF THE MOUTH. 75 

For the fever and rapid pulse, tinctura aconiti, n\, j-iij (0.06- 
0.18 Cc.) every half hour or hour until its physiological effects are 
produced. 

For the enlargement of the organ, either ice constantly applied 
internally and externally, at the angles of the jaw, or the persistent 
use of hot water held in the mouth and externally ; if prompt relief 
does not follow these measures, or if the case is an aggravated one, 
the prompt deep scarification of the tongue must be resorted to. 

If abscesses form, promptly open them and administer quinince 
sulphas. 

If suffocation appear imminent, tracheotomy must be performed. 

For chronic glossitis, the removal of the exciting cause and the local 
use of argenti nitras to the ulcerated edges. 

" For psoriasis of the tongue," the local use of argentum or acidum 
carbolicum. 

The general health must always receive proper attention. 



GANGRENOUS STOMATITIS. 

Synonyms. Cancrum oris ; noma ; water-cancer. 

Definition. An acute, rapidly progressive gangrenous ulceration 
of the mouth, leading to extensive sloughing and destruction of the 
affected tissues. 

Causes. It is probable that gangrenous stomatitis is due to some 
parasitic micro-organism, but its character is as yet unknown. It 
attacks feeble and sickly children by preference; now and then 
observed in adults. 

It is seen as a primary affection and as a sequelae to measles, 
scarlet fever, typhoid and typhus fevers, and pneumonia. 

Pathological Anatomy. The process is essentially a rapidly 
progressive moist gangrene. 

Symptoms. Noma usually begins insidiously by the destructive 
process developing upon an ulcerative stomatitis, or the appearance 
of a sloughing ulcer on the gums or the inside of the cheek of an 
apparently healthy mucous membrane. Often the gangrenous odor 
is the first symptom noted. The cheek swells, becomes (edematous, 
and the skin waxy looking ; within a day or two the process may 
spread, involving the whole side of the face, and as the ulcer becomes 



76 PRACTICE OF MEDICINE. 

deeper and approaches in its progress the integument, the skin be- 
comes red, blue, purple, black, or a combination of these shades, 
followed by the development of a bulla filled with ichorous fluid, the 
skin softening and breaking down. 

The constitutional reaction is very severe ; pulse rapid and feeble ; 
temperature io2°-io4° F. ; extreme prostration ; pain but little com- 
plained of, but the odor fills the house ; diarrhoea is common, hemor- 
rhages from the mouth rare. Death usually occurs in a week to ten 
days, the patient often presenting a frightful picture. Very rarely 
recovery occurs. 

Diagnosis. No other disease or condition can be confounded 
with gangrenous stomatitis. 

Prognosis. Nearly all cases die. 

Treatment. There is but little to say about the treatment of noma. 
Destruction of the ulcer by the use of argentum nitras in stick, fum- 
ing acidum nitricum, or the Paquelin cautery might be tried. Washes 
of antiseptic solutions, and the application of quantities of finely 
powdered acidum boricum are useful. Keep up the strength of the 
patient with ferrum, arsenicum, quinina sulphas, and stimulants. 



DISEASES OF THE STOMACH. 



ACUTE GASTRIC CATARRH. 

Synonyms. Acute simple gastritis ; gastric fever ; bilious fever ; 
acute indigestion ; subacute gastritis. 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the stomach ; characterized by feverishness, loss of 
appetite, nausea, with occasional vomiting, painful digestion, irregu- 
larity of the bowels, and in severe attacks, vertigo {stomachic vertigo). 

Causes. Deficient quantity of or quality in the gastric juice. 
Errors in diet, insufficient mastication of food, swallowing liquids 



DISEASES OF THE STOMACH. 77 

which are either too hot or too cold, and particularly the abuse of 
alcoholic liquors, cold beer, and iced soda-water. Certain drugs in 
medicinal doses, such as iodides, bromides, and arsenic. 

Often secondary to infectious diseases, such as scarlet fever, measles, 
smallpox, diphtheria, and typhoid fever. Occasionally the result of 
wet, changeable weather. 

Pathological Anatomy. The mucous membrane is irregularly 
congested and engorged, and covered with a grayish, semi-transparent 
and tenacious mucus, having an alkaline reaction. The true gastric 
juice is secreted in lessened amount or is entirely suspended. 

Symptoms. At first, loss of appetite, at times disgust for food, 
heavily coated tongue, bad taste and breath, persistent nausea, and 
at times vomiting, first of undigested food, then viscid mucus, acid and 
bitter, and, finally, bilious matter ; moderate irritative fever is present, 
with headache, considerable thirst, and flashes of heat with sensations 
of burning in the palms of the hands and soles of the feet ; acid drinks 
eagerly sought after ; digestion imperfect, giving rise to pain, tenderness, 
feeling of weight, and eructations ; bowels may be loose, but are 
oftener constipated. Vertigo with pain in the nucha is a prominent 
symptom in many cases, causing great anxiety and depression of 
spirits. The urine is scanty, containing lithates and pigment. 

The symptoms are aggravated by errors in diet, and if saccharine 
or fatty articles are taken heartburn occurs. 

Toward the termination of an attack, herpetic eruptions appear 
about the mouth. 

Diagnosis. Acute gastric catarrh with fever may be confounded 
with remittent and typhoid fever of the first week, but all doubts will 
disappear as these maladies develop. 

The vertigo may be mistaken for cerebral disease, but the disap- 
pearance of this symptom when stomachic treatment is inaugurated 
removes all apprehension. 

Prognosis. Favorable. Duration about a week ; recovery slow, 
even under treatment, as far as perfect digestion is concerned. 

Treatment. Give the stomach as complete a rest as possible, and 
as anorexia is a prominent symptom, the error should not be made 
of insisting upon the patient eating for a day' or two at least. 

If the stomach is overloaded, a rare incident, an ipecac emetic, or 
apomorphina hydrochloras, gr. }i (0.008 Gm.), by hypodermic injec- 
tion, is indicated, or, if vomiting has begun, it may be encouraged by 



78 PRACTICE OF MEDICINE. 

swallowing large draughts of hot water, which will act as a sedative 
if the stomach be empty. 

The majority do better by an active purgation with either hydrar- 
gyri chloridi 7nile, gr. v-x (0.32-0.65 Gm.), with sodii bzcarbonas, 
gr. v (0.32 Gm.), followed in six or eight hours with an ounce dose 
magnesii sulphas, or a full dose of Hunyadi Janos water; or small 
doses every two hours of powders containing — 

R. Hydrarg. chlor. mite, gr. %-% .016-.032 Gm. 

Sodii bicarb., gr. ij .13 Gm. M. 

Every two hours for a dozen, followed the second morning after the last 
powder with a saline purgative. 

After the stomach and bowels have been thoroughly cleansed, the 
diet may be more liberal, and some one of the following drugs used : 
tinctura nucis vomica, rr^v-xv (0.3-1 Cc), well diluted, every four 
hours, or fiepsinum or papoid. The following is an excellent 
stomachic sedative : 

R. Sodii bicarb., ^iij 12. Gm. 

Bismuth, subnit., \ ij 8. Gm. 

Aq. chloroformi, f^iij 9°- Cc. 

M. et adde 

Aq. menthoe pip., f^j 30. Cc. 

Aq. lauro-cerasi, f ^ ij 60. Cc. M. 

Sig. — Tablespoonfal four times a day. 



Another excellent formula after the acute symptoms have subsided 



is 



R. Strychninx sulphas, gr. ss .03 Gm. 

Acid, hydrochlorici dil., . . . . f.^iv 15. Cc. 

Glycerini, f 5j 30. Cc. 

Tinct. card. comp. , f'n ss J 5" ^ c " 

Aq. lauro-cerasi, f!|j 30. Cc. M. 

Sic. — One teaspoonful, diluted, four times daily. 



ACUTE TOXIC GASTRITIS. 

Synonym. Toxic gastritis. 

Definition. An acute and violent inflammation of the mucous, 
submucous, and muscular coats of the stomach, with loss of tissue; 
characterized by great pain, constant vomiting of blood-streaked 



DISEASES OF THE STOMACH. 79 

or bloody mucus, and whatever may be ingested, and symptoms 
of collapse. 

Causes. Ingestion of irritant and corrosive poisons, such as the 
mineral acids, arsenic, corrosive sublimate, copper, and carbolic acid. 

Pathological Anatomy. The mucous membrane is vividly 
red and injected, more marked at some portions than at others ; it is 
soft and friable ; erosions are irregularly scattered, and the submu- 
cous, muscular, and at times serous coats show decided destructive 
changes. The gastric tubules are destroyed in large numbers. In 
many cases the oral mucous membrane presents signs of severe in- 
flammation. 

Symptoms. Immediately or soon after swallowing the irritant 
there ensues a deadly nausea, with rapid and persistent vomiting ; 
first, of the contents of the stomach acted upon by the poison, after- 
ward, shreds of mucous membrane and blood clots ; there are also 
present great anxiety and depression, a weak, rapid pulse, slow and 
shallow respiration, cold skin, covered with a cold sweat, intense 
burning pain and heat at the epigastrium, thirst with burning in the 
fauces and gullet, and exhaustive purging ; the features are more or 
less retracted or sunken; these symptoms terminating in collapse and 
death, or slow convalescence and recovery with a crippled stomach. 
If death be delayed some hours, marked nephritic symptoms appear. 

A diagnosis of the character of the poison swallowed is often 
afforded by the stain of the lips, face, and mucous membrane, to wit : 
sulphuric acid, blackish eschar ; nitric acid, yellowish eschar ; caustic 
potash, spreading widely and softening the tissues ; corrosive subli- 
mate, whitish or glazed ; carbolic acid, white and corrugated ; chro- 
mic' acid, yellowish-white, changing to grayish brown. 

Prognosis. Very grave. Many perish from shock, and the de- 
struction of the mucous membrane of the stomach, which prevents 
nourishing. Early treatment when no perforation of the walls of the 
stomach has occurred' and recovery is possible, the organ being ever 
after much weakened. 

Treatment. At once, hypodermic injection of morphines sulphas, 
repeated as often as indicated. 

Vomiting should be encouraged by the free use of demulcents. 

If the case be seen within a short period of the swallowing of the 
poison, the proper antidote should be used, but if some hours have 
elapsed, it is useless. 



80 practice of medicine. 

Irritant and Corrosive Poisons. 
Poison. ■ Antidotes. 

{Chalk, magnesia (plaster of wall in emergency), 
solution carbonate soda, emollient drinks, fixed 
oils. 

Ammonia ("household ( , 7 . . ... ,-, , .-, . 

• },,. v • Vinegar mixed with a bland oil, and sustain 

ammonia ) or lini- < . b . ., A , . ' 

1 heart with strychnia, 

ment. ^ J 

( Moist peroxide of iron (obtained from perchloride of 

. . J iron and calcined magnesia) or the ferri oxidum 

j hydratum, U. S. P., charcoal, ammonia to nos- 

[ trils. 

f Castor oil, olive oil, and the sulphate of magne- 

Carbolic acid. -j sium or sodium as a chemical antidote. Prompt 

( stimulation. 

r-u • -j f Acetate of iron, ten per cent, solution nitrate sil- 

Chromic acid. < c • • 1 V i -i i_ 

I. ver, forming insoluble silver chromate. 

r* . ,,. f Albumen, white of egg (four grains sublimate 

Corrosive sublimate. < . ' , .. c \ n -n 

|^ require white ot one egg), hour, milk. 

Iodine. Demulcent drinks, starch or flour in water. 

{Magnesia, turpentine, demulcents. Wash stom- 
ach by use of stomach tube or pump and warm 
water, afterward using Epsom salts. 
Silver nitrate. Solution common salt in demulcent drinks. 

Soda, or "caustic pot- f Olive oil, demulcents, vinegar, lemon juice, and 
ash." "Lye." \ hypodermically stimulants. 

c i i . f Albumen or white of egg, stomach pump, and 

Sulphate copper. -< , A , . A , &&» t r > 

r l r ( wash stomach with soap water. 

Ice, internally and externally, gives great relief. The stomach 
should be washed out with the stomach tube or pump, thereby re- 
moving any remaining poison, which at the same time acts as a 
sedative to the inflamed membrane. Bismuthi subnilras, gr. xx-xxx 
(1.3-2 Gm.) every hour or two, is beneficial. 

Milk and lime-water \s the only food that should be given by the 
stomach, enemata being used to support the system. Strychnines sul- 
phas and atropine sulphas hypodermically to sustain the heart and 
nervous system. 



DISEASES OF THE STOMACH. 81 

CHRONIC GASTRIC CATARRH. 

Synonyms. Chronic gastritis ; chronic dyspepsia ; drunkards' 
dyspepsia. 

Definition. A chronic catarrhal inflammation of the stomach, 
with thickening of the coats and atrophy of the gastric glands ; char- 
acterized by tenderness over the epigastrium, impaired appetite, pain- 
ful and imperfect digestion, thirst, and great depression of spirits or 
melancholia. 

Van Valzah describes three forms of chronic gastritis — viz. : (i) 
Gastritis catarrhalis chronica, or chronic asthenic gastritis ; (2) gas- 
tritis glandularis proliferans, or chronic hypersthenic gastritis ; (3) 
gastritis glandularis atrophicans, or progressive atrophy of the gastric 
glands. 

Causes. Repeated attacks of acute gastric catarrh ; habitual and 
excessive use of spirituous liquors, tea, coffee, and the free use of ice- 
water during and between meals ; improperly prepared and unsuit- 
able food ; irregularity of meals and imperfect mastication ; excessive 
tobacco-chewing ; malaria ; disease of the heart, lungs, pleura, liver, 
or kidneys, producing chronic congestion of the stomachic vessels ; 
cancerous or other degenerative diseases of the stomach. 

Pathological Anatomy. The mucous membrane is of a brown- 
ish or slate color, elevated into ridges from hypertrophy, the result of 
constant congestion ; the peptic glands first increase in size, then un- 
dergo granular change, atrophy of their cells resulting. The mucous 
membrane is covered with a thick, alkaline, tenacious mucus. Ewald 
describes the minute anatomy as that of a parenchymatous and inter- 
stitial inflammation, which may lead to such widespread degenera- 
tion of the glandular elements that ultimately scarcely a trace of 
secreting tissue remains. These changes may affect the entire organ 
or be limited to portions of the stomach. 

Symptoms. The persistent and manifold symptoms of indiges- 
tion, varying somewhat with the extent of the mucous surfaces and se- 
creting glands involved, are the first indications of the disease, such 
as loss of appetite, disagreeable feeling of gnawing and at times full- 
ness in the stomach, tenderness at the epigastrium, but slightly influ- 
enced by eating, prominence of the epigastrium, from distention by 
decomposing gases, occasional 7iausea and vomiting after meals, of 
undigested food, or, when the stomach is empty, of colorless fluid. A 



82 PRACTICE OF MEDICINE. 

colorless vomit joined to symptoms of long-continued indigestion is 
always very characteristic of chronic gastritis. Drunkards suffer 
from an early morning vomit consisting of glairy mucus and saliva 
swallowed during sleep, raised only after great retching. The tongue 
is usually heavily coated, although it may be clean ; thirst is often 
constant, water and more frequently stimulants being craved ; burn- 
ing at the pit of the stomach and under the sternum (heartburn) is 
very common; pain, sharp and diffused, after eating; the bowels are 
constipated, the urine high-colored and contains an excess of phos- 
phates or urates, or exhibits crystals of oxalate of lime. In advanced 
cases the circulation is feeble, there is depression of spirits amount- 
ing in some instances to delusional melancholia; sleeplessness is 
persistent, and occasionally there are attacks of vertigo (stomachic 
vertigo), which greatly alarm the patient. All of these symptoms re- 
sult from either a deficient secretion of the gastric juice or from a less- 
ened proportion of hydrochloric acid in the juice secreted, and also 
from the excessive mucus and from diminished peristalsis of the stom- 
ach, such morbid conditions favoring the fermentation and decom- 
position of the food. Follicular pharyngitis of an aggravated type 
adds to the general distress of the patient. The imperfect digestion 
causes more or less loss of flesh, the fat disappearing, the muscles re- 
laxed and the skin dry, harsh, and of a dirty-pale color, and not in- 
frequently eczema and other cutaneous diseases develop. 

Diagnosis. Chronic gastritis is associated with so many chronic 
diseases that a correct diagnosis is of great importance. Among the 
affections likely to lead to error in diagnosis are gastric ulcer, gastric 
cancer, gastric dilatation, cerebral vertigo, cardiac disease, and dis- 
ease of the kidneys and liver. 

Prognosis. Complete recovery is hardly to be expected, but 
great amelioration of symptoms occur and with guarded diet and 
mode of life good health may be enjoyed for many years. It is usually 
a disease of middle life. 

Treatment. The first indication is the correction of the indiges- 
tion, which is usually the most pronounced and distressing symptom ; 
this is accomplished by carefully regulating the amount and charac- 
ter of the food used, avoiding fatty, saccharine, and starchy articles or 
highly seasoned food or stimulants. A milk diet is beneficial, to 
which may be added beef in small amounts, eggs, oysters, and a few 
fresh green vegetables. If beef is allowed, it had better, for a time, 



DISEASES OF THE STOMACH. 83 

be in the form of " Salisbury steaks " — made of lean beef shaped into 
flattened cakes and broiled. This or whatever other articles of diet 
are allowed to be taken an hour or more after sipping slowly a half 
pint (237 Cc.) of water, at iio°-i5o°. The hot water should also be 
taken before retiring. 

The second important symptoms to correct are the constipation, 
which is often most obstinate, and clearing the stomach of the 
tenacious mucus which neutralizes whatever gastric juice is secreted. 
Appropriate purgatives are the natural mineral waters, such as Bed- 
ford Water, Saratoga, Hunyadi Janos, or — 

|& . Magnesii sulph., gr. Ix-cxx 4.-8. Gm. 

Sodii et potass, tart., gr. xxx-lx 2.-4. Gm. 

Acid, tartaric, gr. xx 1.3 Gm. M. 

Dissolved in a glass of water and drank, effervescing, an hour before break- 
fast. 

An excellent purgative and promoter of stomachic peristalsis 
is : 

R. Ext. cascarse sagradse fid., . . . . fjfj 30. Cc. 

Glycerini, f^ ss I 5- Cc. 

Tinct. nucis vomicae, f,^ ss I 5- Cc. 

Aq. chloroformi vel inf. glycyrrh , f ^j 30. Cc. M. 

SiG. — One to two teaspoonfuls after meals, well diluted. 

For the purpose of cleansing the stomach of the tenacious mucus 
as well as for its stimulating action on the glands, lavage or irrigation 
of the stomach with lukewarm water is valuable. The water can be 
medicated with a solution of salt, or sodii bicarbonas or acidum 
boricum. Ewald considers the morning, on an empty stomach, the 
preferable hour for the practice of stomach washing. 

Those patients who object to lavage obtain relief from the system- 
atic drinking of one-half to one pint (237-475 Cc.) of hot water an 
hour before meals, as mentioned above. 

For the irritable condition of the mucous membrane, associated 
with the poor appetite and slow digestion, good results are reported 
from stronlii bromidum, gr. xv (1 Gm.), well diluted, before meals. 

For the morbid condition of the mucous membrane may be used, 
liq. potassii arsenitis, tt\j-ij (0.06-0.12 Cc), before meals, or bismuth, 
subnil., gr. x-xx (0.65-1.3 Gm.), on a comparatively empty stomach, 
one hour before or two or three hours after meals ; it may at times be 



84 PRACTICE OF MEDICINE. 

combined with sodii bicarbonas. The following combination often 
gives great comfort for a long time if the diet is regulated : 

R. Sodii bicarb., giv 15. Gm. 

Bismuth, subnit., Zvj 24. Gm. 

Aquoe chloroformi, f 3 iij 90. Cc. 

M. et adde 

Aquoe lauro-cerasi, f^ n j 9°- Cc. 

Strychninse sulph., gr. j .065 Gm. M. 

Sig. — Two teaspoonfuls at meal-time in a little water. 

Argenti ' nitras , gr. )( (0.016 Gm.), or argenii oxidum, gr. ss-j (0.032- 
0.065 Gm.), in pill, before meals, or acidum hydrochloricwn dilutum, 
rr^x-xv (0.6-1 Cc), in water, before meals, are useful remedies. 

Pain is so severe in some cases that resort must be had at times to 
opium or belladonna in small doses, after meals. Emplastrwn bella- 
donna over the stomach is useful. Cocaincz hydrochloras, gr. l /e 
(0.01 Gm.), is also recommended. 

To aid digestion, acids, pepsinum, pancreatinum, papoid, and 
bitters are of value, the following being an excellent prescription : 

R. Pepsini (cryst. ), gr. lx 4. Gm. 

Acid, hydrochlorici dil., . . . . fgiv 15. Cc. 

Glycerini, f^iv l S- Cc. 

Strychninse sulph. , ...... gr. ss .032 cm. 

Aquce chloroformi, . . q. s. adf^iij ad 90. Cc. M. 

SlG. — One teaspoonful at meal-time in a little water. 

Rest of the body and mind is almost as important as rest of the 
stomach. 



GASTRIC ULCER. 

Synonyms. Peptic ulcer; chronic gastric ulcer; perforating 
ulcer. 

Definition. A solution of continuity, involving the mucous 
membrane and one or more layers of which the walls of the stomach 
are composed ; characterized by gastric pain, disorders of digestion, 
and vomiting of blood. 

Causes. There is no generally accepted view of the etiology. 
Van Valzah truthfully says, "Ulcer is not a disease with a single 
cause and one mode of genesis." Ewald attributes it mainly to an 



DISEASES OF THE STOMACH. 85 

"altered composition of the blood, and the resulting insufficient 
nourishment of the cells." Riegel claims that the ulcer is due to a 
self-digestion of the stomach at a limited spot, and it is certainly 
more than a coincidence that in ulcer the gastric juice is nearly 
always hyperacid. More common in young females than males. 
Anaemia or its sequela a chief factor ; disorders of menstruation ; 
blows over the epigastrium; burns of the integument; syphilis; 
tuberculosis. Virchow claims that emboli or thro7nbi form in the 
nutrient gastric arteries which have lost their tonicity, an ulcer form- 
ing at the point of obstruction. 

Pathological Anatomy. In the majority of cases the ulcer is 
solitary. The posterior wall near the pylorus is the most frequent 
location. 

In a typical case there is a circular hole, with sharp borders in the 
serous coat of the stomach ; the loss of substance is greater in the 
mucous membrane than in the muscular coat, and greater in this 
than in the serous coat, so that the ulcer looks like a shallow funnel, 
the apex at the outer wall, the base at the inner wall of the stomach ; 
it is first round, growing, becomes elliptical, bulging at portions, be- 
coming irregular ; size, from %-yb inch in diameter. When the 
ulcer heals before all the coats are perforated, a distinct cicatrix 
marks the location. During its progress nutrient vessels are eroded, 
causing profuse hemorrhage. Chronic gastric catarrh complicates 
the majority of cases. 

Symptoms. More or less prominent symptoms of indigestion. 
Pain constant at the " pit of the stomach," increased by taking food, 
especially of an irritating character, the pain often felt in the back, 
of a burning, gnawing character. Tenderness at one or more points, 
extending from the front to the back. Vomiting is almost as constant 
as pain, coming on soon after eating if the ulcer is at the cardiac ori- 
fice, an hour or so after if it is located at or near the pylorus. Rejected 
matter may be undigested or partly digested food, or simply acrid 
mucus. Vomiting of blood in large quantities and arterial in color is 
almost diagnostic of gastric ulcer; the blood may be dark in color if 
it has remained in the stomach some time before being rejected. 

Severe and frequent attacks of gas tralgia may add to the suffering 
of the patient. The general condition of the patient is not significant, 
some being greatly debilitated, while in others the nutrition is but 
little deranged. 



86 PRACTICE OF MEDICINE. 

Duration. The ulcer is slow in forming, and runs a very chronic 
course, an average duration being, perhaps, about a year. Cases are 
recorded in which the disease has suddenly developed and terminated 
by perforation, peritonitis, and death within two weeks, but such in- 
stances are rare. 

Diagnosis. Duodenal ulcer presents symptoms so akin to those 
of gastric ulcer that a differential diagnosis is impossible. 

Chronic gastritis is often confounded with gastric ulcer; the dis- 
tinctive points are : absence of vomiting of blood, no localized con- 
stant pain aggravated by food, and no tenderness in the back ; while 
the symptoms of indigestion are marked and persistent, with, as a 
rule, a history of spirit drinking, and the age of the patient — middle 
life ; ulcer in the young. 

The points of distinction between gastric cancer and gastralgia will 
be pointed out when considering those affections. 

Prognosis. Gastric ulcer is a dangerous disease, and the prog- 
nosis should be very guarded. Recoveries are frequent. 

The dangers -axe perforation, ■peritonitis, or fatal hemor?'hage. 

Treatment. Give the stomach as complete a rest as possible ; 
this is accomplished by rectal alimentation, or when it cannot be 
carried out, an exclusive milk diet, adding lime-water to enable the 
stomach to better retain the milk, or a strictly skimmed-milk diet, to 
which may also be added lime-water ; the amount of milk should be 
one or two ounces every two hours. Rest in bed and keeping the 
stomach empty by rectal feeding give the most favorable condition 
for the healing of the ulcer. If a severe hemorrhage occurs and col- 
lapse is imminent, a pint (475 Cc.) of warm physiological solution of 
common salt (3j or 4 Gm.) to one pint (475 Cc.) should be slowly 
introduced into the rectum. Additional amounts of the salt solution 
may be injected into the subcutaneous cellular tissues. At the same 
time sustain the heart by hypodermic injections of strychnines sulphas, 
7iitroglycerinum, and a?nmonia. 

To correct hyperacidity use a combination of sodii bicarbonas and 
magnesia calcined, in large doses after each feeding, if stomach ali- 
mentation is allowed, and, if not, every four hours. Belladonna is a 
valuable drug for excessive acid secretion. 

For pain, small doses of ?norphincz sulphas should be used as 
needed. 

For hemorrhage, hypodermic injections of ergota are most reliable. 



DISEASES OF THE STOMACH. 87 

Plumb i acetas, gr. j-iij (0.065-0.2 Gm.), arrests the bleeding and 
exercises a favorable influence over the ulcer. An ice-cap or bag 
over the epigastrium is most valuable. 

For the ulcer, liquor potassii arsenitis, 1T\J— ij (0.06-0.13 Cc), every 
five hours, has given excellent results in several cases treated by the 
author; bismuthi subnitras, gr. xx-xxx (1.3-2 Gm.), combined with 
sodii bicarbonas, gr. v (o 32 Gm.), three times a day, often does well; 
argenti nilras, gr. X~K (0.016-0022 Gm.), every four hours, or 
argenti oxidum, gr. ss (0.032 Gm.), every four hours, are at times 
beneficial. 

For the associated anaemia, ferrum and arsenicum, alone or com- 
bined, are indicated. Ferri albuminate would seem to be particularly 
indicated, or the following : 

R. Pulv. ferri albuminatis, gr. ij .13 Gm. 

Sodii arseniat., . . gr. Jq •°°3 Gm. M. 

Ft. pil. or capsule, taken three or four times daily. 

The bowels must be kept soluble. 

If perforation and peritonitis result, full doses of opium are indi- 
cated. Surgical aid is indicated for the perforation. 



GASTRIC CANCER. 

Synonyms. Cancer of the stomach; gastric carcinoma. 

Definition. A peculiar malignant growth, occurring for the most 
part at the pyloric extremity of the stomach, making constant pro- 
gress, destroying the gastric tissues and infecting the lymphatic 
glands ; characterized by disorders of digestion, pain, vomiting, 
marked anaemia, and terminating in all cases by the death of the 
patient. 

Cause. Hereditary. Develops after forty years, for the most 
part. The question of a cancer germ is gaining ground. Twice as 
many cancers occur in women as in men. 

Pathological Anatomy. Cancer of the stomach is the most 
common form of cancer. It is, as a rule, a primary cancer. The 
variety is most commonly the scirrkus, next in frequency, medullary, 
the least frequent, colloid. As regards the location, eighty per cent. 



88 PRACTICE OF MEDICINE. 

occur at the Pylorus. Those portions of the stomach remote from the 
cancer are normal or comparatively healthy. 

It originates usually in the tubules, rapidly infiltrating the remain- 
ing tissues, thickening everywhere as it progresses, and either remains 
a hard nodulated mass or undergoes ulceration. The hard nodulated 
growth at the pylorus constricts the orifice, resulting in dilatation of 
the stomach. The lymphatic glands adjacent to the stomach are 
infiltrated, secondary cancers resulting. Ulceration into an artery 
causes hemorrhage into the peritoneum, resulting in local peritonitis. 

Complications. Fatty heart ; thrombosis ; tuberculosis. 

Symptoms. The development of gastric cancer is insidious, 
with indigestion, progressive in character, associated with marked 
acidity, flatulency, and a fetid breath. 

The majority of cases have vomiting, occurring immediately after 
eating, if the disease is at the cardiac orifice, and some hours after if 
located at the pylorus ; if much dilatation of the stomach develop, 
the vomiting occurs some days after eating. The rejected matter is 
food in various stages of digestion, associated frequently with black 
grumous masses of altered blood and tissues. Hematemesis is fre- 
quent, rarely profuse, usually oozing of blood altered into a dark 
brown or black color — "coffee-ground" vomit or the oozing blood 
passes into the intestinal canal, causing tary stools. 

Absence of hydrochloric acid in the stomach is a very constant 
observation in gastric cancer. Boas and Stewart (D. D.), in 1895, 
found, by the use of the test-meal (flour soup), that lactic acid was 
always present in gastric cancer, and they were unable to find this 
acid in any other stomach condition. 

Pain, marked and constant, dull, heavy, increased by pressure or 
food, seldom lancinating. Marked ancemia and emaciatio7i soon 
occur, the surface having an earthy or fawn color. CEdema of the 
ankles is an early diagnostic symptom in carcinoma of the stomach, 
often occurring as early as the third month, and may progress to a 
general anasarca. A tumor is found in three-fourths of the cases, 
occupying the epigastric region, not moving with inspiration. As the 
carcinoma progresses, the lymphatic glands enlarge, particularly the 
supra-clavicular and inguinal glands. Jaundice frequently occurs, 
and the liver is enlarged. The urine often contains albumin. An 
irregular temperature occurs in some patients. 

The duration of the disease is about one year, the patient dying 



DISEASES OF THE STOMACH. 89 

from exhaustion, peritonitis, or he?norrhage, the mind clear but 
despondent. 

Diagnosis. The continuous absence of free hydrochloric acid 
and the presence of lactic acid in the stomach are diagnostic signs 
of great value in determining the probable existence of gastric cancer. 
It is possible to make a positive diagnosis by study of the rational 
symptoms and the aid of the X-rays. 

Chronic gastric catarrh differs from gastric cancer in the absence 
of a tumor, bloody vomit, characteristic pain, peculiar color of the 
surface, dropsy, and the rapid emaciation. 

Gastric ulcer differs in the character of the pain, age of the 
patient, large amount and color of bloody vomit, the absence of a 
tumor, and progressive emaciation. Still the diagnosis is often 
difficult. 

Abdominal tumors may raise the question of a gastric cancerous 
tumor; the points of distinction are the characteristic symptoms of 
gastric cancer, and that abdominal tumors, especially of the liver and 
spleen, the ones most apt to cause error in diagnosis, are influenced 
by inspiration, while tumors of the stomach are not so influenced. 

When a scirrhus of the pylorus lies upon the aorta, a pulsation may 
be communicated to it, raising the question of aneurism of the 
abdominal aorta, but the expansile pulsation of aneurism (Corrigan's 
sign) is wanting, as are the other symptoms of the affection, and if 
the patient is made to rest upon his hands and feet, the stomachic 
tumor falls away from the aorta and pulsation ceases. 

Mikuliez claims that, by the use of his gastroscope, regular rhyth- 
mical motions can be seen when the pylorus is not the seat of cancer, 
and that such movements are absent when it is the seat of cancer. 

Prognosis. Unfavorable. Internal medication offers no hope, 
the patient usually succumbing from starvation. 

Gastric carcinoma occurring under thirty years of age is rapidly 
fatal, not conforming to the usual symptoms as seen later in life ; the 
characteristic cachexia is commonly absent and hsematemesis is rare. 

Treatment. We possess no means of arresting the disease, 
although it is but fair to mention that in Germany condurango in the 
form of decoction is recommended as a specific in gastric cancer. 
I have faithfully used the fluid extract with some benefit for the 
accompanying gastritis, but without effect on the tumor. 

Six operations have been recommended for the relief of stenosis of 



90 PRACTICE OF MEDICINE. 

the pylorus: ist. Pylorectomy ; 2d. Gastro-enterostomy ; 3d. Gas- 
trectomy; 4th. Gastrostomy; 5th. Duodenostomy ; 6th. Digital di- 
vulsion of the pylorus. Professor Billroth has excised the pylorus, 
thereby prolonging life ten months in one case and five years in an- 
other. 

During the past year (1898) two successful operations for the re- 
moval of the entire stomach have been reported, both patients being 
alive some weeks after. 

For acidity and fetor of the breath, acidum carbolicum, gr. %-}i 
(0.016-0.022 Gm.), or carbo animalis purificatus, gr. x-xxx (0.65-2 
Gm.), affords some relief. 

For vomiting and pain, bismuth and opiu?n, or lavage or the wash- 
ing out of the stomach. The lavage should be performed an hour 
before breakfast, followed in half an hour with : 

& . Strychnince sulph., gr. ss .032 Gm. 

Acid, hydrochlor. dil., f^iv x 5- Cc. 

Inf. condurango, . . . q. s. adf^viij ad 240. Cc. 
M. et ft. tablespoonful before meals, diluted. 

Yor pain, morphina, or the following, recommended by Osier : 

R . Morphinse sulph., gr. y& .008 Gm. 

Sodii bicarb., . . gr. v .3 Gm. 

Bismuth, subnit., gr. x .6 Gm. M. 

Sic. — Repeated p. r. n. 

Avoid stimulants. 



GASTRIC DILATATION. 

Synonyms. Gastrectasis ; pyloric obstruction ; pyloric stenosis. 

Definition. An abnormal increase of the cavity of the stomach, 
with the walls either hypertrophied, or decreased in thickness; char- 
acterized by pronounced indigestion, vomiting of partly digested and 
partly decomposed food at intervals of a day or two, and noisy mov- 
ing of flatus within the abdomen (borborygmus). 

Causes. Most common cause a stricture of the pylorus, the result 
of cancer ; pressure of tumor against the pylorus, preventing exit of 
stomachic contents. Loss of muscular tone, occurring in anaemia. 
Prof. Bartholow cites cases resulting in excessive beer-drinkers, who 
drank thirty to forty glasses of beer habitually, every day. 



DISEASES OF THE STOMACH. 91 

Pathological Anatomy. When obstruction exists at the pylo- 
rus, the whole organ is dilated, with hypertrophy of the muscular layer 
of the stomach. In dilatation without pyloric obstruction, the muscu- 
lar layer is thinner than normal, paler in color, and presents signs of 
fatty degeneration ; the mucous membrane is also pale, thin, and 
without rugae. 

Symptoms. Those of the disease producing the obstruction plus 
those of obstinate chronic gastric catarrh, with characteristic vomitifig ; 
the cavity having a greatly increased capacity, large accumulations 
take place, which are rejected every day or two, partly digested and 
partly decomposed. Regurgitaiioji of partly digested aliment, acrid, 
acid, and offensive, is very common. Bowels constipated, the stools 
hard and dry. 

Physical signs of gastric dilatation are : on inspection, abnormal 
prominence of the whole epigastric region, with a tumor in the pyloric 
region which seems to be connected with the stomach ; percussion, 
if empty, tympanitic note extending to or below the umbilicus, 
having a metallic quality ; if the stomach be filled, high-pitched flat 
note ; auscultation, splashing and rumbling sound, the succussion 
sound being distinct if the body be shaken. 

Diagnosis. Copious vomiting of food partly digested, once in 
twenty-four hours or less often, epigastric distress and pain resulting 
from foul-smelling and acid eructations and from obstinate constipa- 
tion. And on percussion the tympanitic note of the stomach as low 
or lower than the umbilicus, with some dullness, may be due to food or 
liquid in stomach. 

If a doubt then exist, give large amount of food and note dullness, 
or, what is not so pleasant, sodii bicarbonas, gr. xv (i Gm.),with acidum 
tartaricum, gr. xx (1.3 Gm.), and the tympanitic outline of the stomach 
will be evident. 

Dr. Leonard has determined the presence of gastric dilatation by 
the X-ray and use .of bismuth solution to produce a shadow in stomach. 

Penzoldt's modification of Piorry's method of determining gastric 
dilatation is to withdraw the contents of the stomach by means of the 
oesophageal tube and then refilling the stomach with fluid. By noting 
the lower limit of percussion dullness thus produced, the lower bor- 
der of the stomach can be accurately determined. 

Treatment. Regulated diet. Restrict the use of fluids, using a 
" dry diet" exclusively. 



92 PRACTICE OF MEDICINE. 

If the result of pyloric stenosis, one of the operations mentioned 
for pyloric cancer may be indicated. 

Regardless of the cause, washing out the stomach with the stomach 
tube every day or two, gives relief, and, if no stricture be present, 
administer strychnines sulphas or nux vomica, and very favorable 
results may follow. 

GASTROPTOSIS. 

Definition. A displacement of the stomach downward, associ- 
ated with prolapse of the bowel (enteroptosis or Glenard's disease) 
and prolapse of the kidney (nephroptosis). 

Causes. Relaxed condition of the abdominal walls due to 
impaired development or loss of tension, causing improper intra- 
abdominal pressure ; wearing corsets or other tight, unyielding gar- 
ments ; occupations favoring stooping posture, leading to decreased 
tension of the abdominal walls, such as seamstresses, tailors, and 
shoemakers, or other sedentary work ; frequent pregnancies, which 
stretch the abdominal muscles. 

It is probable that there exists a predisposition to imperfect devel- 
opment of abdominal and other muscles, or their early loss of tension 
with wasting. 

More common in women than men, as would be expected from a 
study of the causes. 

Anatomical Conditions. The transverse colon is the first 
organ to prolapse, soon followed by the ascending colon. The 
stomach is tilted, as it were ; its lower border reaching below the 
umbilicus, while its lesser curvature lies between the ensiform carti- 
lage and the umbilicus. In some cases the pyloric end is down to or 
below the umbilicus without as much prolapse of the fundus. The 
right kidney is displaced and often floating or movable. The left 
kidney is less often displaced. 

Any or all of the conditions named may be associated with any of 
the organic gastric conditions. 

Symptoms. Impaired digestion with eructations of gases. Dis- 
tress or feeling of weight after eating, often amounting to intense 
pain. Loss of flesh with marked ancemia and 7ieurasthenic symptoms 
are almost characteristic of the gastric and intestinal prolapse. Con- 
stipation is the rule, although cases with diarrhoea have been reported. 



DISEASES OF THE STOMACH. 93 

Physical phenomena. In the standing position the lower part of 
the abdomen projects and the upper part sinks in. In the recumbent 
position the abdomen shows a lateral extension. Aortic pulsation is 
frequent. There is often " a ridge lying across the abdomen" to be 
determined by palpation. Glenard termed this ridge the " corde- 
colique transverse" and thought it was due to a prolapse of and 
partial occlusion of the transverse colon. Other observers think it is 
the pancreas that is felt on account of the prolapse of the transverse 
colon. Inflation of stomach often detects its prolapsed position with 
a lowered gastric splashing. The X-ray, with the aid of the bismuth 
solution for shadow, will determine the location of the organ. 

Treatment. Unless surgery can give aid, medication is but pal- 
liative. Abdominal bandages are recommended, but seem of small 
use. The chief indication is to improve the general health. 



GASTRIC HEMORRHAGE. 

Synonyms. Haematemesis ; gastrorrhagia. 

Definition. Gastric hemorrhage is not, strictly speaking, a dis- 
ease, but a symptom ; still, vomiting of blood occurs under such a 
variety of conditions that a separate consideration is desirable. 

Causes. Ulcer of the stomach ; cancer of the stomach ; cirrhosis 
of the liver ; scurvy ; purpura ; haemophilia ; hemorrhagic malarial 
fever ; congestion of the liver or spleen ; cirrhosis of the liver ; 
vicarious at menstrual period ; yellow fever ; toxic gastritis. 

Symptoms. Added to the symptoms of the cause of the hem- 
orrhage, are a feeling of faintness and sinking at the pit of the stom- 
ach, followed by the ejection of blood of a black, grumous, or coffee- 
ground appearance. Rarely, and then generally in gastric ulcer, the 
ejected blood may have a bright red appearance, the gastric juice not 
having had time to act upon it. If the amount of blood escaping 
into the stomach is large, blood will be voided by stool. 

Diagnosis. Hemorrhage fro?n the lungs may be confounded 
with gastric hemorrhage. In the former, the blood is red, is coughed 
up, not vomited, and is associated with a history of pulmonary dis- 
ease. The chief point of distinction between pulmonary hemorrhage 
and the vomiting of red blood is that in the former you can discern 
rales on auscultating the chest, and they are absent in the latter. In 



94 PRACTICE OF MEDICINE. 

hemorrhage from the stomach there is almost invariably food mixed 
with the blood. 

Prognosis. Depends entirely upon the cause, the most unfavor- 
able being the result of either gastric ulcer, cancer, hepatic cirrhosis, 
or haemophilia. 

Treatment. Complete rest in bed. Ice, internally and applied in 
bladders over the epigastrium and along the spine, or hot water, as 
hot as can be borne, in quantities of four to six ounces at very fre- 
quent intervals. 

Hypodermic injections of morphines sulphas quiet the patient's fear, 
and at the same time have a constringing effect upon the vessels. 
Extractum ergottz fluidum or ergotin hypodermically after the patient 
is quieted, or liquor ferri subsulphaiis, ntj-v (0.06-0.3 Cc), well 
diluted, by stomach. 

Cases resulting from congestion of the liver or spleen are benefited 
by saline purgatives. 

Allow no food by the stomach for several days, nourishing the 
patient by rectal alimentation. 

The hemorrhage controlled, the future treatment is guided by the 
exciting cause. 

GASTRALGIA. 

Synonyms. Cardialgia; gastrodynia; stomachic colic; spasm 
of stomach ; neuralgia of the stomach. 

Definition. A painful condition of the sensory nerves of the 
stomach, induced by various sources of irritation ; characterized by 
violent paroxysms of gastric pain and spasm, associated with feeble 
cardiac action, and symptoms of collapse. 

Causes. The affection belongs to the group of neuralgias. The 
most important factor in its causation is general nervous depression 
or neurasthenia ; other causes are gastric cancer or ulcer, malaria, 
rheumatic or gouty diathesis, syphilis, anaemia, and certain articles of 
diet. Occurring in chronic nervous affections, the so-called " gastric 
crises." 

Symptoms. Like most neuroses, gastralgia is distinguished by 
\ts paroxysmal character. Romberg thus describes an attack : 

" Suddenly, or after a feeling of pressure at the praecordiumi there 
is severe griping pain in the stomach, usually extending to the back, 



DISEASES OF THE STOMACH. 95 

with a feeling of faintness, a shrunken countenance, cold hands and 
feet, and an intermittent pulse . The pain becomes so excessive that 
the patient cries out. The epigastrium is either puffed out, like a ball, 
or retracted, with tension of the abdominal walls. There is often pul- 
sation in the epigastriwn. External pressure is well borne, and not 
unfrequently the patient presses the pit of the stomach against some 
firm substance, or compresses it with his hands. Sympathetic pains 
often occur in the thorax, under the sternum, and in the oesophageal 
branches of the pneumogastric, while they are rare in the exterior of 
the body. 

"The attack lasts from a few minutes to half an hour or longer; 
then the pain gradually subsides, leaving the patient much exhausted; 
or else it ceases suddenly, with eructation of gas or watery fluid, or 
with vomiting, and with a gentle, soft perspiration, or with the passage 
of reddish urine." 

Besides such severe attacks, we often see painful sensations in the 
epigastrium, of various degrees of intensity, with passing faintness or 
sinking at the "pit of the stomach," associated with heartburn, or 
pyrosis, ending with sensation of hunger, drowsiness, and a free dis- 
charge of clear urine of low specific gravity. 

Diagnosis. From myalgia of the abdominal muscles, by the pain 
of gastralgia being more acute and lancinating, accompanied by 
nausea and vomiting and the absence of tenderness on pressure. 

From intercostal neuralgia, by the fact that in this affection the pain 
is in the left hypochondrium, with painful spots along the course of 
the nerve "trunk and at the spine, and absence of nausea and 
vomiting. 

From gastric cancer, by the age, character of the vomited matter, 
constancy of the pain, the cachexia, emaciation, and the tumor. 

From gastric ulcer, by the localized pain and its constancy, with 
tenderness and vomiting of blood, and constant dyspeptic symptoms, 
which is not the case in gastralgia. 

From hepatic ox gall-stone colic, by the pain being to the right of 
the median line radiating to the right and to the right scapula and 
shooting toward the right ilium and the sclerotic jaundice after an 
attack. 

Prognosis. As to perfect recovery, unfavorable, but not danger- 
ous to life. A chronic affection, in that attacks are prone to return 
from time to time. The cause has much to influence a radical cure 



9G PRACTICE OF MEDICINE. 

Treatment. For the paroxysm, hypodermic injections of mor- 
phines sulphas, gr. yi-% (0.02-0.03 Gm.), or the stomachic adminis- 
tration. of the " compound of anodynes," the so-called chlorodyne, in 
doses of tt^x-xxx (0.6-2 Cc.) p. r. n. The relief afforded by opium in 
some form is so decided that it is apt to lead to the opium habit when 
the attacks are frequent. A mild attack may be relieved by antipyri?i, 
gr. x (0.65 Gm.). A hot-water bag over the stomach is of great 
value. In recurring attacks Van Valzah recommends : 

R . Codfin., g r - X - OI ^ Gm. 

Ext. cannab. indicae, g r - To •°°^ ^ m - 

Atropinse sulphas, gr. 2^ .00032 Gm. 

Aconitinae, gr. ^^ .00016 Gm. M. 

Ft. capsul. 

SiG. — One every four or six hours. 

Galvanization often gives prompt relief. 

In the interval, regulated diet and one or more of the following 
remedies : argenti nitras, qtiinince sulphas, arsenicum, bismuth sali- 
cylas,ferrum, liquor iodii co?np., or small doses of potassii iodidum. 



ATONIC DYSPEPSIA. 

Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. 

Definition. A functional derangement of the stomach, with either 
deficient secretion in the quantity ox quality of the gastric juice; char- 
acterized by disorders of the functions of digestion and assimilation 
and the presence of sympathetic nervous symptoms. 

Causes. Imperfect mastication ; bolting of food ; eating large 
quantities of food ; same diet long continued ; depressed nervous 
system, from worry and fatigue ; sedentary habits or occupations. It 
is often inherited. 

Symptoms. Perverted appetite, capricious or lost ; difficult di- 
gestion, a feeling of weight or fullness in the epigastrium ; acidity 
from the decomposition of albuminoids ; heartbwn, flatulency \ regur- 
gitation % or vojniting of portions of partly digested food or acrid 
fluid — water- brash or pyrosis. Pain or soreness at the "pit of stom- 
ach " during digestion. Tongue either clean or broad, flabby, and 
pale, showing marks of the teeth. Bowels constipated ; urine gener- 
ally scanty and high-colored, with excess of urates or oxalates, or, in 



DISEASES OF THE STOMACH. 97 

persons of nervous type, it is pale, of low specific gravity, and con- 
tains phosphates. Drowsiness after meals, with wakefulness at night, 
defective memory, headache, and absent mental vigor, with flashes of 
heat, followed by more or less perspiration. Palpitation of the heart 
with irregularity in rhythm. 

Varieties of Dyspepsia. — I. Nervous dyspepsia, atonic form, seen in 
active business or busy professional men, especially those of thin, 
spare build, of nervous temperament, who eat meals rapidly and 
hurry off to their business. These cases present all the marked 
nervous phenomena, such as drowsiness after meals, and feeling 
worse after a nap ; inability for mental exertion after meals, defective 
memory, headaches, at times vertigo and sleepless nights. II. Flat- 
ulent dyspepsia, seen in hysterical individuals, and showing immense 
development of gas throughout the abdomen, associated with vertigo 
and mental worry or hypochondria. III. Acid dyspepsia, water- 
brash. Seen when the diet is coarse. Acidity of the gastrointes- 
tinal canal and of the urine. IV. Irritative dyspepsia. Vomiting a 
prominent symptom. In these cases the tongue is small, red, and 
pointed. 

Prognosis. With careful living, dyspepsia, functional in charac- 
ter, is curable. It has been aptly termed " remorse of the stomach." 

Treatment. The most important indication is to regulate the 
diet. Forbid saccharine, starchy, or fatty articles of food. Eat small 
amounts at a time, underojpae, meats or " Salisbury steaks," eggs, 
fish, oysters, and green vegetables, with stale or brown bread. Per- 
fect insalivation and mastication. Rest after eating, from a half to 
an hour. Allow but small quantities of liquids with the meals. 
In the vast majority of cases, forbid the use of stimulants with the 
meals. 

Aid digestion with pepsinum, with or without acidum hydrochlori- 
cum dilutum. 

R. Pepsini purse, ^j 4. Gm. 

Acid, hydrochlorici dil., . . . - fgiv 15- Cc. 

Glycerini, f ^ iv 15. Cc. 

Aq. lauro-cerasi, f^ij 60. Cc. M. 

SiG. — One teaspoonful with meals, diluted. 

Excellent results have followed the use of a new remedy known as 
taka- diastase, gr. ij-iv (0.13-0.26 Gm.) at meal time. 
9 



98 PRACTICE OF MEDICINE. 

Sumulate stomachic peristalsis with nux vomica, gentian, or cin- 
chona. 

For acidity, alkalies at time of acidity, the very best being sodii 
bicarbonas. 

Y ox flatulency , carbo animalis purificatus, gr. x-xx (0.65-1.3 Gm.), or 
one or more of the carminatives, with tinctura nucis vomicce before 
meals. 

F "or pyrosis, bismuth, gr. xx (1.3 Gm.), and pulvis aromaticus, gr. v 
(0.32 Gm.). 

For vomiting, sodii or strontii bromidum in small doses, or acidum 
carbolicum, gr. Ye-% (0.011-0.016 Gm.), three or four times daily, or 
chloral hydrate, gr. x-xv (0.65-1 Gm.), in a demulcent by the mouth 
or rectum, repeated p. r. n. 

For constipation, resina podophyllum at bedtime, or Hunyadi Janos 
water before breakfast, hot, or — 

R. Ext. cascaras sagradae fid., . . . f^j 30. Cc. 

Tinct. nucis vomicae, f.l ss l S- Cc 

Syr. zingib., f.^ ss J 5- Cc. 

Inf. sarsaparillae, . . . q. s. ad f^iij ad 90. Cc. M. 

SiG. — Teaspoonful three times daily, diluted. 

For ance7nia, massa ferri carbonatis or ferri lactas. 

Irrigation of the stomach or lavage often gives remarkable relief. 
The drinking of hot water one-half to one pint an hour before meals 
is of benefit. 

A homely but efficient combination for atonic dyspepsia associated 
with scanty, acid urine and constipation, is — 

R. Sodii bicarbonatis, gij 8. Gm. 

Tinct. nucis vomicae, f.^iv 15. Cc. 

Tinct. capsici, f^j 4. Cc. 

Tinct. rhei, f Jiss 45. Cc. 

Inf. gentian, comp., . . . . adfjvj ad 180. Cc. M. 

SiG. — Half tablespoonful after meals, in water. 

I have seen excellent results in many cases of dyspepsia and indi- 
gestion from the following combination : 

&. Papoid (purae), gr. xxx 2. Gm. 

Sodii bicarb., gr. lx 4. Gm. 

Pulv. zingib. jam., gr. v .3 Gm. M. 

Et capsul. or pil. No. xx. 

SiG. — One at meal-time and bedtime. 






DISEASES OF THE INTESTINAL CANAL. 99 



DISEASES OF THE INTESTINAL CANAL. 



INTESTINAL INDIGESTION. 

Synonym. Intestinal dyspepsia. 

Definition. A derangement in the functions of intestinal diges- 
tion, resulting in the more or less complete decomposition of the 
chyme, caused by defects in the pancreatic, biliary, or intestinal 
secretions or from deficient peristalsis, one or more of these, singly 
or combined ; characterized by abdominal pain and distention and 
tympanites developing some hours after meals, and nervous perturba- 
tion, anaemia, and emaciation. 

Causes. Imperfect diet ; over-eating ; irregularity in eating ; de- 
ficient exercise ; worry ; immoderate use of tobacco or stimulants ; 
diseases of the stomach, intestinal tract, liver, or pancreas ; malaria. 
Frequently inherited. 

Symptoms. Intestinal indigestion may be either acute or chronic, 
the latter the more common. 

Acute variety, the result of an irritant in the duodenum, rapidly 
developed pain, flatulency, borborygmi, slight feverishness, coated 
tongue, loss of appetite, headache, pains in the li?nbs, usually termi- 
nating in a mild attack of diarrhoea. 

If the attack develops rapidly, the sudden formation of gases 
causes a paroxysm of colic. 

Severe attacks are associated with disordered hepatic function, 
light-colored stools, slight jaundice, and high colored urine. In these 
severe attacks the symptoms develop gradually with general malaise, 
or abruptly with chill or chilliness followed by fever ioo°-io2°, in- 
creased pulse, headache with or without vomiting, the tongue white 
coated, soon becoming red, dry, and glazed, with abdominal pains 
increased by pressure, tympanites and flatulency succeeded by diar- 
rhoea, the stools averaging from two to a dozen, at first soft and nor- 
mal with fecal odor and color, later becoming watery and frothy with 
a most persistent, offensive odor, containing mucus and particles of 
undigested food. The reaction of stools is alkaline, rarely acid. The 



100 PRACTICE OF MEDICINE. 

microscope shows epithelial cells, round cells, occasionally blood- 
cells, bacteria, Charcot's crystals, crystals of oxalate of calcium, 
calcium phosphate, etc. Cramps in lower limbs, often very severe. 

Chronic variety, resulting from a greater or less decomposition of 
the partly altered food from the stomach. Pain, varying in character, 
occurring f^om two to four or six hours after meals, with slight 
tenderness and some fullness in the right hypochondrium, epigas- 
trium, or the umbilical region. Tympanites and borborygmi are 
marked, the result of gaseous accumulations which have developed 
from the decomposition of the intestinal contents. Dyspnoea, the 
result of pressure against the diaphragm, is of frequent occurrence. 
Marked nervous phenomena develop, the result of the anaemia from 
deficient assimilation and from the depressing influence on the 
nervous system of the absorption of the " gases of decomposi- 
tion." 

The skin is harsh and dry, the bowels are sluggish or constipated, 
the urine is high colored, of increased density, decidedly acid, 
and, on cooling, deposits lithates, uric acid, and oxalate of lime 
crystals. 

Functional derangement of the liver follows after a time, adding to 
the general discomfort. 

AncEmia and emaciation result if the attack be protracted from the 
imperfect secondary assimilation. 

Diagnosis. With our present knowledge it is usually impossible 
to designate forms of intestinal indigestion due to defects in the 
quantity or quality of either the pancreatic, biliary, or intestinal 
secretions. 

Acute intestinal indigestion differs from gastric indigestion in the 
time of development of the various phenomena, in the latter the 
symptoms appearing almost immediately after meals, while in the 
former not appearing until two, four, or six hours after. 

Chronic intestinal indigestion may mislead the physician if the 
various nervous phenomena are of a marked character, and a careful 
history of the case is not developed. 

Prognosis. Favorable if proper and early treatment be inaugu- 
rated, unless the result of an organic lesion. 

Treatment. Acute variety, the result of undigested food, is best 
treated by opium in some form, to relieve the acute suffering, warmth 
to the abdomen, and a prompt cathartic to cause its rapid expulsion, 



% 


.02 Gm. 


y 


.13 Gm. 


Ve 


.01 Gm. 


u ) 


.2 Gm. 



DISEASES OF THE INTESTINAL CANAL. 101 

or six or eight calomel powders two or three hours apart, followed 
the next morning by a saline — 

R. Hydrarg. chlor. mit., gr. 

Sodii bicarb., . gr. 

Pulv. ipecac. , gr. 

Sacch. lact. , gr. iij .2 Gm. M. 

Ft. charta. 

After which stimulate the gastro-intestinal canal with : 

f£. Tinct. nucis vomicce, f^iv 15. Cc. 

Acid, hydrochlorici dil., . . . fgiv 15. Cc. 

Tinct. card, comp., f^iv 1 S- Cc. 

Ess. pepsin., q. s. ad f 5 iij ad 90. Cc. M. 

SlG. — Teaspoonful every three hours, diluted. 

For the more severe variety of intestinal indigestion (or catarrh), 
wash out large bowel with — 

R. Magnesii sulph., %] 30. Gm. 

Glycerini, f 5j 30. Cc. 

Aquae bul., f'^iv I2 °« Cc. M. 

Slowly injected into bowel from a fountain syringe. 

Internally either of the following excellent combinations : 

R. Naphtalini, gr. 

Bismuth, salicyl., gr. 

Acid, carbolici, gr. 

Glycerini, f^j 

Aq. chloroformi, ....... fjiij 90. Cc. M. 

SlG. — Two teaspoonfuls every two or three hours, diluted. 

Or— 

U . Sodii phosphat., %] 30. Gm. 

Acid, phosph. dil., 
Syr. limonis, . . 
Aq. chloroformi, 



XXX 


2. Gm. 


lxxx 


6. Gm. 


iv 


.26 Gm. 




30. Cc. 


J 


90. Cc. 



fgiv 15. Cc. 

f|j 30. Cc. 

f5iij 90. Cc. 

fliiiss 100. Cc. M. 



Aq. menth. pip., 
SlG. — One tablespoonful after meals, well diluted. 

In all cases carefully designate the character and amount of food, 
and times of administration. 

Chronic cases. Of the first importance is the diet, which should be 
restricted in amount and confined almost entirely to articles which 
are readily digested in the stomach, such as beef, eggs, and milk. 



102 PRACTICE OF MEDICINE. 

Aid intestinal digestion by the administration of — 

R. Papoid, gr. j-ij .065-. 13 Gm. 

Naphtalini, gr. j .065 Gm. 

Ext. nucis vomicae, gr. y$ .022 Gm. M. 

Ft. pil. 

One such to be taken every four or six hours. 

Or liquor pajicreaticus, f3j-iv (4-15 Cc); or extractum pancreatis, 
gr. ij-v (0.13-0.3 Gm.), with sodii bicarbonatis, gr. v-x (0.3-0.6 Gm.), 
two or three hours after meals ; or fel bovis purificatum, gr. j-iij 
(0.065-0.2 Gm.), after meals. 

Excellent results from the use of the following pill : 

R. Sodii arseniat, gr. ^ .003 Gm. 

Strychninse sulph., gr. 3V .002 Gm. 

Pepsinoe purse, gr. ij .13 Gm. 

After each meal. 

For constipation, bitter waters, such as Bedford, Friedrichshall, 
Pullna, or Hunyadi Janos, or resina podophyllum, or extractum 
cascarcE sagrada fluidum, at bed-time. 



INTESTINAL COLIC. 

Synonyms. Enteralgia ; tormina ; gripes. 

Definition. A spasmodic contraction of the muscular layer of 
the intestinal tube ; characterized by acute paroxysmal pain near the 
umbilicus, relieved by pressure, and associated with feeble cardiac 
action. 

Causes. Constipation; presence of indigestible food ; collections 
of flatus; an abnormal amount of bile discharged into the intestines; 
lead poisoning; syphilis; chronic malaria ; rheumatism; hysteria. 

Symptoms. Romberg thus describes a paroxysm : " There are 
attacks of pain, spreading from the navel over the abdomen, alter- 
nating with intervals of ease. The pain is tearing, cutting, pressing, 
most frequently twisting, pinc/iing, accompanied by peculiar bear- 
ing-down pains. The patient is restless, and seeks relief "in changing 
his position and in compressing the abdomen; his surface maybe 
cold and his features pinched. The pulse is small and hard. The 
abdomen is tense, whether puffed up or drawn inward. There are 



DISEASES OF THE INTESTINAL CANAL. 103 

often nausea and vomiting, and desire for stool. There is usually 
constipation, but sometimes the bowels are regular or even too loose. 
Duration from a few minutes to several hours, relaxing at intervals. 
The attack ceases suddenly, with a feeling of the greatest relief, 
although some soreness remains for a few days." 

Lead colic is always preceded by symptoms of lead poisoning, to 
wit: slate-colored skin, dark gums showing a blue line, heavy breath, 
with sweetish metallic taste, obstinate constipation, impaired appetite, 
slow pulse, and contracted abdominal walls. 

Diagnosis. Gastralgia differs from colic, in the pain being in the 
epigastric region and associated with disorders of digestion. 

In hepatic colic, or the passage of gallstones, the pain is in the 
hepatic region, attended with soreness over the gall bladder, and 
retching and vomiting, followed by jaundice and the presence of bile 
in the urine. 

In nephritic colic, the pain follows the course of one or both ureters, 
shooting to loins and thigh, with retraction of the testicle of the affected 
side, strangury, and bloody urine. 

In uterine colic, the pain is in the pelvis, and associated with men- 
strual disorders, in fact, a dysmenorrhoea. 

In ovarian colic or neuralgia, pain or pressure over the ovaries, 
with hysterical phenomena. 

Inflammatory disorders of the abdomen differ from colic by the 
presence of fever and tenderness on pressure. 

Prognosis. Most favorable. Death is the rarest termination 
possible. 

Treatment. Relief of pain is the first indication, and is best ac- 
complished by a hypodermic injection of morphines sulphas, gr. l /6- l /i 
(0.011-0.022 Gm.), which has tho additional advantage of relaxing 
the spasm, thereby favoring the action of purgatives, which should 
soon follow. One of the best in colic, no matter from what cause, is 
masses hydrargyrum, gr. v-x (0.3-0.6 Gm.), or hydrargyri chloridum 
mite, gr. ]/ z (0.03 Gm.) every half hour until four or five grains are 
taken, followed by a mild saline cathartic. 

After the relief of the pain and free action of the bowels, the cause 
of the attack should be ascertained and corrected, to prevent future 
suffering. 

For lead colic, morphina sulphas for the pain ; oleum ricini or 
magnesii sulphas, Z\ (4 Gm.) every hour, for the constipation, and 



104 PRACTICE OF MEDICINE. 

potassii iodidum, gr. v-x (0.3-0.6 Gm.) after meals, or syrupus 
acidi hydriodici, f^j-iv (4-15 Cc.) after meals, diluted, to eliminate 
the metal from the system. Excellent results often follow a free or 
several small venesections in lead poisoning. 

Gratifying results in attacks of lead colic have been reported from 
tumblerful doses of oleum olives, repeated until some six ounces 
(180 Cc.) have been used. It is said to be curative in lead poisoning, 
in daily doses of two ounces, continued for some time. 



CONSTIPATION. 

Synonyms. Intestinal torpor ; costiveness. 

Definition. A functional inactivity of the intestinal canal, either 
due to atony of the muscular coat, causing lessened peristalsis, or to 
a deficiency of intestinal and biliary secretion ; characterized by a 
change in the character, frequency, and quantity of the stools. 

Causes. Dyspepsia; character of the food; habits of the patient, 
as sedentary habits and neglecting calls of nature ; diseases of the 
stomach and liver; malaria; lead poisoning ; syphilis. 

Symptoms. In the normal condition the majority of persons 
have one stool each day, although it is not to be considered abnormal 
if more or less than that number occur. 

The bowels are moved every three ox four days, with great straining 
and distress, the/ace often flushed, the cerebral vessels full ; leaving 
an uneasy sensation in the rectum. 

Or in other cases the bowels may be relieved once a day, but the 
stool is small and hard, causing great distress, and tenesmus, or teaz- 
ing. 

Another group of cases rx&ve frequent stools during the day, small 
and non-formed, due to retained hardened feces acting as an irritant 
upon the rectum. 

The change in the character of the stools is soon followed by 
symptoms of dyspepsia, headache, mental torpor, vertigo, palpitation 
on exertion, and in many cases with great distention of the abdomen. 

Prognosis. Death never results from functional constipation. 

Treatment. The successful treatment depends upon the removal 
of the cause and the hearty co-operatio7i of the patient. 

First, the patient must have a regular hour each day for going to 



DISEASES OF THE INTESTINAL CANAL. 105 

stool, and must remain a sufficient time to permit a thorough evacua- 
tion of the bowels, assisting, until habit of daily stools is formed, by 
a warm water injection. 

Second, the diet must be carefully regulated, as concentrated foods 
increase the costive habit, so that those predisposed should eat bulky 
foods, much vegetables and fruits. 

Third, purgative mineral waters or cathartic medicines are to be 
used with caution, their reckless administration often causing more 
injury than benefit. 

Fourth, either of the following formulae, aided by the enforcement 
of the above rules, will give good results : 

R. Ext. nucis vomicse, g r - X .016 Gm. 

Ext. belladonnse alco., g r - X * 01 ^ Gm. 

Ext. aloes aqua., gr. ss .032 Gm. 

Pulv. rhei, gr. j .065 Gm. 

Olei cajuputi, TT\, j .06 Cc. M. 

In pill, at bedtime ; and after a week, every second or third night. 

R • Resina podophyl., 
Ext. physostig. , 
Ext. belladonnae alco. , 

Alomi, aa gr. X aa .016 Gm. 

In pill, every night, or second or third night. 

R. Ext. cascarae sagradoe fid. , . . . TT\,xx 1.3 Cc. 

Glycerini, tt\xx 1.3 Cc. 

Syr. sarsaparillse, V(\xx 1.3 Cc. 

Hour after meals, or once a day, as indicated. 

All cathartics and purgatives are improved by the addition of a 
small amount of sulphur praecipitatum. 

One of the very best purgatives is an early morning dose of magnesii 
sulphas (Epsom salts). Another excellent tonic purgative is aloinum, 
gr. yi-% (0.008-0.016 Gm.), after meals. 

Success often follows an enema of glycerinum, f^j-iv (4-1 5 Cc), or 
a suppository of glycerinum. 

Electricity to the abdomen is worth a trial ; one pole over abdomen, 
the other at anus, using either galvanism or faradism. Kneading the 
abdomen is frequently of benefit. 



10 



106 PRACTICE OF MEDICINE. 



DIARRHCEA. 



Synonyms. Enterorrhoea ; alvine flux ; purging. 

Definition. Frequent loose alvine evacuations, without tenes- 
mus; due to functional or organic derangement of the small intes- 
tines, produced by causes acting either locally or constitutionally. 

Causes. Those acting locally, such as indigestion, indigestible 
food, impure food and water, irritating matters or secretions poured 
into the bowels, or entozoa, cause the flux by a direct irritation of the 
mucous surface. 

Attacks of diarrhoea due to constitutional derangement may be 
secondary to such diseases as tuberculosis, fiyamia, albuminuria, 
typhoid fever, or disturbances of the functions of other organs, giving 
rise to vicarious fluxes. 

Atmospheric changes, as well as a sudden mental shock, will often 
produce an attack of diarrhoea in those predisposed. 

Forms. Acute and chronic. 

Symptoms. Acute diarrhoea presents itself in several varieties, 
the result of the particular cause. 

Feculent diarrhoea. A few hours after meals the patient feels 
colicky pains and flatulency, with a desire for stool. There is often 
nausea, coated tongue, but seldom vomiting. The pain is generally 
relieved by the purging which ensues. The stools have a feculent 
character, are of brown fluid, containing faeces, often offensive, the 
color becoming lighter after four or five evacuations. Constitutional 
symptoms are wanting. 

This form is the result of overeating, eating too rapidly, or indi- 
gestion of different forms, or worms in the intestinal canal, and 
patients generally recover in a day or two. 

Lienteric diarrhoea. In this form there is, with the frequency of 
evacuations, a want of assimilation of food, which passes through the 
intestines more or less unaltered. The stools are frequent, mucous 
or serous, more or less covered with bile, mixed with undigested food. 
In this form the patients emaciate rapidly, owing to the deficient 
assimilation, the digested portions of the food being hurried on by the 
increased peristalsis of the irritated bowel. It is usually subacute in 
its course. 

Bilious diarrhasa. The stools are frequent, green or yellow, with 



DISEASES OF THE INTESTINAL CANAL. 107 

scalding sensations at the anus and griping pains in the abdomen. 
Excessive biliary secretion is the irritating cause. 

Any of the above forms may pass into chronic diarrhoea by exciting 
permanent diseases of the intestines. Diarrhoea due to constitutional 
causes will be mentioned when speaking of those conditions. 

Chronic diarrhoea results from repeated attacks of the acute form. 
or is the result of some cachexia. The sympto?ns, so far as the stools 
are concerned, are much the same as in the acute disease, except 
they are paler, whence it has been termed white flux ; in addition, 
dyspeptic symptoms, aphthous condition of the mouth and tongue, 
flatulency, colic, einaciation, and ancemia. The appetite is at times 
capricious, again impaired. Exacerbations result from indiscretions 
in diet and from the sudden onset of damp weather. 

Prognosis. Favorable in feculent a.nd bilious forms; unfavorable 
in lienteric and chronic forms when emaciation begins. Diarrhoea 
occurring as a symptom, the prognosis is controlled by the original 
disease. 

Treatment. Acute diarrhoea. If the tongue is heavily coated, 
the breath fetid, and the stools not excessive in number, it is well to 
clear the intestinal canal with a laxative such as oleu?n ricini or a 
saline. For children between one and two years of age : 

R. Pulv. ipecac, gr. ss .032 Gm. 

Pulv. rhei, gr. X _ K .016-.022 Gm. 

Sodii bicarb., gr. ss-ij .032-. 13 Gm. M. 

Every four hours until the character of the stools changes. 

As a rule, however, the stools have become so frequent when ad- 
vice is sought that the time for laxatives has passed, and someone of 
the following combinations is indicated : 

R. Salol, gr. xx-xxx 1.3-2. Gm. 

Bismuth subnit. , 3] 4- Gm. 

Sacch. lac, 3J 4- Gm - M- 

Ft. chart. No. x. 

SlG. — One every two or three hours, reducing the dose for children 

Or— 

R. Bismuthi salicylat, gr. xxx 2. Gm. 

Morphincesulph., gr. j .065 Gm. M. 

Ft. chart. No. vj. 

SlG. — One every three hours. 



108 PRACTICE OF MEDICINE. 

Or the following modification of " Squibb's diarrhoea mixture": 

R . Tinct. opii deodorat., f^iv J 5- Cc. 

Tinct. camphorae, f.^i y J S' Co 

Tinct. capsici, fgij 8. Cc. 

Chloroformi pune, f 7, iss 6. Cc. 

Spts. vini gallici, f^j 30. Cc. 

Vini pepsini, ad fjiij ad 90. Cc. M. 

Sig. — One teaspoonful, p. r. n. 

Or the following, which I have always found successful : 

R. Tinct. opii deodorat., f ^ iv 15. Cc. 

Spts. chloroformi, f^ij 8. Cc. 

Acid, sulphuric, dil., fjfj 30. Cc. 

Vini pepsini, q. s. adfjiij ad 90. Cc. M. 

SiG. — One teaspoonful in water after each stool. 

For the bilious form : 

R . Hydrargyri chlor. mitis, .... gr. y% .008 Gm. 

Sodii bicarb., gr. ij .13 Gm. 

Pulv. opii, g r - X - ol6 Gm. M. 

In powder, every two or three hours, until eight powders are used, followed 
by large doses of bismuthum and pepsinum. 

In all acute forms restricted and regulated diet are imperative, pure 
milk with liquor calcis being the most suitable. 

In adults, an opium suppository often checks a flux that is uninflu- 
enced by opium internally. 

In lienteric or dyspeptic diarrhoea a carefully regulated diet and 
either of the following combinations : 

1£ . Pepsini glycerit., f^j 30. Cc. 

Liq. potassii arsenit., t^xx 1.3 Cc. 

Tinct. opii deodorat., f ^ ij 8. Cc. 

Aq. chloroformi, ... q. s. ad fjiij ad 90. Cc. 
SiG. — One teaspoonful at meal-time. 

Or— 

I£ . Papoid gr. xx 1.3 Gm. 

Bismuth, subnit., 3J 4. Gm. M. 

Ft. chart. No. x. 

Sig. — One at meal-time. 

Chronic diarrhoea. Bismuth, gr. xxx-xl (2-2.6 Gm.), in milk, 
every four hours; Hope's camphor mixture, f]fj (30 Cc), every four 



DISEASES OF THE INTESTINAL CANAL. 109 

hours ; or cupri sulphas, gr. T ^ (0.005 Gm.), ext. opii, gr. T ^ (0.005 
Gm.), every four hours ; or argenti nitras, gr. l /e (0.01 Gm.), ext. opii, 
gr. ^(0.011 Gm.), every five hours; may all be used with more or 
less success ; when dry tongue and great flatulency use : 

R . 01. terebinthinse, f z j 4. Cc. 

01. amygdal. express., f3 ss I 5- Cc. 

Tinct. opii, fzij 8. Cc. 

Mucil. acacise, f z * v J 5- Cc. 

Aq. lauro-cerasi, f|> ss I 5- Cc. M. 

SlG. — f 3 j every three or four hours, diluted. 

The diet should be nutritious in character, and moderate stimulants 
are indicated. Activity of the skin and kidneys should be encour- 
aged. 

All varieties of intestinal catarrh or diarrhoea are benefited by a 
few days' rest in bed and daily hot baths. 



CATARRHAL ENTERITIS. 

Synonyms. Intestinal catarrh ; acute diarrhoea ; inflammation 
of the bowels. 

Definition. A catarrhal inflammation of the mucous membrane 
of the small intestines ; characterized by fever, pain, tenderness, and 
looseness of the bowels. When the catarrh is limited to the duode- 
num it is termed duodenitis, and there is some jaundice. 

Pathological Anatomy. There first ensues hyperemia of the 
mucous membrane and intestinal glands, manifested by redness, 
swelling, and azdema ; this is followed by increased secretio?t, and an 
overgrowth and desquamation of the epithelium, together with a copi- 
ous generation of young cells. As a result of the hyperaemia, rupture 
of the capillaries and extravasation of blood often occur. 

The swollen glands show a strong tendency to ulcerate. This 
catarrhal process may involve the entire tube or be limited to portions 
of it. If the catarrhal changes extend to the ileum, the solitary and 
Peyerian glands show swellings that might be mistaken for the changes 
of typhoid fever. 

Causes. A specific virus seems probable in some cases. Per- 
haps a ptomaine poisoning. Improper and indigestible food ; summer 



HO PRACTICE OF MEDICINE. 

temperature and exposure to cold and wet, while perspiring. Swal- 
lowing fish-bones, cherry-stones, unmasticated kernels of nuts, etc. 

Symptoms. Begins with languor, followed by chilliness and 
fever, the temperature ranging at io2°-io3°; this is followed by pain, 
colicky and paroxysmal in character, situated above the umbilicus, 
localized tenderness, and loose evacuations. Nausea and vomiting 
often occur. The bowels are at first constipated, followed by per- 
sistent diarrhoea ; the stools contain but little fecal matter, are yellow 
ox greenish-yellow in color, mixed with undigested food ; if the stools 
are numerous, they become whitish and watery, the so-called " rice- 
water" discharges. No blood in the stools. The appetite is im- 
paired, and this, with the want of assimilation and great waste, soon 
produce extreme weakness and emaciation, which is always more 
marked in children. I have frequently noted a peculiar abdominal 
eruption in severe cases of intestinal catarrh, occurring as isolated 
dark-red spots, larger than those of typhoid fever, lasting, each, 
twenty-four hours, disappearing on pressure and with the decline 
of fever. 

Duration. In mild cases, four or five days; severe cases con- 
tinue, more or less marked, for a week or two. 

Diagnosis. From colic, by the absence of tenderness and fever, 
and presence of constipation and its paroxysmal character. 

From typhoid fever, by the absence of prodromes, characteristic 
step-like temperature record, characteristic eruption, enlarged spleen, 
and peculiar character of the stools. 

For points of distinction from dysentery or peritonitis, see those 
affections. 

Prognosis. Favorable, if early and proper treatment is em- 
ployed. 

Treatment. Rest the bowels by a restricted diet, such as milk 
and lime-water, or weak mutton or chicken soups, with well-boiled 
rice added. 

Keep the patient quiet in bed, a difficult matter in the case of 
children. 

For adults, opium is the remedy, in doses to control the symptoms; 
mild doses do well with — 

li . Ext. opii, gr. x /i-)/ 2 .016-.032 Gm. 

Camphone pulv., gr. iij .2 Gm. M. 

In pill, every three hours. 



DISEASES OF THE INTESTINAL CANAL. Ill 

Or— 

R. Tinct. opii deodorat., ..... Yf\x .6 Cc. 

Liq. potassii citrat., f^ij 8. Cc. M. 

Every hour until opium effect. 

The strength and the frequency of administration of either of these 
formulae must be governed by the severity of the attack. 

Salol, gr. j-iij (0.065-0.2 Gm.), alone or combined with bismuthi 
salicylas, gr. x-xv (0.6-1 Gm.), every few hours, is often of value in 
intestinal catarrh, although my experience is more favorable to 
opium. 

If vomiting is annoying, all other treatment must be discontinued 
until it has been controlled, the following being usually efficient : 

Jt . Hydrargyri chlor. mite, .... gr. ^ .008 Gm. 

Sodii bicarbon., gr. ij .13 Gm. 

Sacch. lac, gr. ij .13 Gm. M. 

Give every hour or two, dry, on tongue. 

For children : 

R . Tinct. opii deodorat. , TT\J .06 Cc. 

Bismuth, submit., gr. v .32 Cc. 

Mist, cretse, fgj 4. Cc. M. 

Every two hours, for a child of one year. 

If the disease shows the least tendency to linger, the acid treatment 
should be substituted, one of the best formulae being " Hope's Cam- 
phor Mixture." The following, which I have used with much success 
in the insane wards of the Philadelphia Hospital, where, at times, we 
see a good deal of intestinal catarrh, and which I have named " Mis- 
tura enterica," is generally satisfactory: 

5c. Spts. camphorse, f^j 30. Cc. 

Acid, sulphurici dil., f<|i ss 45- Cc. 

Tinct. opii deodorat., f Ij 30. Cc. 

Tinct. capsici, f^ ss *5- Cc. 

Spts. chloroformi, f.! s s 15- Cc. 

Spts. vini gallici, . . q. s. adf^vj ad 180. Cc. M. 

SiG. — One to two teaspoonfuls, well diluted, every three or four hours. 

Locally. Poultices, warm fomentations, such as a turpentine 
stupe, or ung. belladonna or oleum camphoratce, are agreeable. 



112 PRACTICE OF MEDICINE. 



CROUPOUS ENTERITIS. 

Synonym. Membranous enteritis. 

Definition. A croupous inflammation of the mucous membrane 
of the small intestines ; characterized by tenderness, paroxysmal 
pain, moderate fever, and the formation and discharge at stool of 
membranous shreds or casts. 

Causes. A disease of adult life. The female sex more liable 
than the male, and neuralgic, nervous, hysterical, or hypochondriacal 
subjects are more subject to it than are other types. 

A peculiar state of the nervous system seems necessary to its pro- 
duction. It is not a frequent disease. 

Pathological Anatomy. A subacute inflammation of the small 
intestine, during which the mucous membrane becomes covered with 
a whitish or grayish-white, firmly adherent, membranous deposit, 
cemented together by a coagulable exudation, and prolonged by 
rootlets from the under surface into the intestinal follicles. 

Symptoms. Begins by feverishness, feeling of soreness and dis- 
tention of the abdomen; these are followed by pains of a colicky 
character, severe and depressing, felt around the umbilicus, asso- 
ciated with tenderness, continuing for half an hour, an hour, or longer, 
and after a longer or shorter interval occurring again ; these pheno- 
mena continue for a day or two, when looseness of the bowels with 
distressing pain and tenesmus occur, the stools containing mucus, 
with or without blood, and shreds of membrane or cylindrical casts of 
the bowel. Great relief follows the discharge of shreds, although a 
feeling of rawness or soreness persists for a few days. 

Preceding the local manifestations of the disease are attacks of 
hysteria, hypochondriasis, neuralgia, nervousness, or excitability. 

The paroxysms recur at intervals of a week or two, or after several 
months ; as long an interval as three years between attacks is 
recorded. 

Diagnosis. Peritonitis may be suspected until the characteristic 
stools occur. 

Dysentery is excluded when the shreds and casts of membrane ap- 
pear. 

Prognosis. Favorable as to life, but one of the most difficult of 
diseases to eradicate. 



DISEASES OF THE INTESTINAL CANAL. 113 

Treatment. The diet is an important factor, and preference 
should be given to coarse articles instead of to liquids. 

For the pain and suffering, opium in some form is indicated, the 
most effective being a hypodermic injection of morphince sulphas. 

For constipation during a paroxysm, an emulsion of oleum ricini 
with terebinthina is of benefit. Constipation must always be avoided. 

To prevent a return of the paroxysm, either liquor potassii arsenilis, 
nvj-ij (0.06-0.12 Cc), before meals, or hydrargyri chloridian corro- 
sivum, gr. ¥ x ¥ (0.001 Gm.), three times a day, with a course of oleum 
morrhuce, seems to answer in the majority of cases. Prof. Da Costa 
speaks highly of pix liquida in some form, as an alterative to the 
mucous membrane. 



CHOLERA MORBUS. 

Synonyms. Sporadic cholera ; English cholera ; bilious cholera. 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the stomach and intestines, of sudden onset ; charac- 
terized by violent abdominal pains, incessant vomiting and purging, 
cold surface, rapid, feeble pulse, spasmodic contractions of the 
muscles of the abdomen and extremities, and prostration. 

Causes. A disease of summer and early autumn, climatic influ- 
ence being an important factor. Its prevalence during certain 
seasons seems to indicate a specific cause. Irritants of all kinds, 
unripe fruits and vegetables, and fermentation of food. Probably a 
ptomaine poisoning. 

Pathological Anatomy. Cases in which death has occurred 
within a few hours present no pathological changes. 

Generally, however, the gastro-intestinal mucous membrane is 
congested' and denuded of epithelium; the solitary and Peyerian 
glands are swollen and prominent. The blood is thick, and dark in 
color; the kidneys are enlarged and congested; and in prolonged 
attacks there are appearances of granular changes in the muscular 
system. 

Symptoms. Onset sudden and violent, and, unfortunately, gen- 
erally after midnight, with chilliness, intense nausea, vomiting, and 
purging, accompanied with distressing burning or tearing abdominal 
pains or colic. The vomited inatter at first consists of the ordinary 



114 PRACTICE OF MEDICINE. 

contents of the stomach, and the stools of ordinary faeces, but soon 
the discharges by vomit and stool are liquid, whitish, or of a green or 
yellowish tint ; if the attack is severe or protracted, the discharges 
are of the " rice-water'" character. The patient is rapidly emaciated 
and redttced in strength, the body shrinks, the surface is cold and 
covered with a clammy sweat, and the pulse is small and feeble, 
hitense thirst is present, and when drink is given it is at once 
rejected. 

Aggravating the distress of the patient are severe cramps of the 
muscles, and especially those of the calves, and of the flexors of the 
thighs, forearms, fingers, and toes. 

Termination. Mild cases often terminate favorably without treat- 
ment, the patient able to be around in a day or two, although weak. 

Severe cases, the vomiting and purging cease after some hours, but 
the patient remains weak, with irritable stomach and bowels for a 
week or two. 

Grave cases, the true cholera type, recover from the prostration 
very gradually ; reaction coming on slowly and usually passing into a 
typhoid condition of some weeks' duration.' 

Diagnosis. Asiatic cholera and cholera morbus are easily con- 
founded during an epidemic of the former, and there are no positive 
points of discrimination, unless the comma bacilli of Koch are proven 
to be always in the true cholera stools. 

Irritant poisons, such as tartar emetic, elaterium, or other sub- 
stances, cause vomiting and purging, similar to cholera morbus, and 
are only discriminated from it by the clinical history and cause. 

Prognosis. In the majority of cases favorable. The mortality is 
about five per cent. 

Treatment. At once, regardless of the cause, a hypodermic in- 
jection of morphines sulph., gr. Y%-)A, (0.008-0.022 Gm.), and atropines 
sulph., gr. jfa (0.00054 Gm.), to be repeated in half an hour if no 
improvement; for patients who object to the hypodermic method, 
opium in some form by the mouth or rectum, giving the preference 
to the liquid preparations. 

Camphora and opiu?n combined often act well, or the "enteric 
mixture" mentioned on page 1 11, and if much depression, small 
doses of brandy or dry champagne. 

The intense thirst must not be gratified by the use of liquids, unless 
very hot, but small pellets of ice by the stomach are grateful. 



DISEASES OF THE INTESTINAL CANAL. ]15 

If the vomiting and purging- continue, make use of — 

R . Bismuth, submit, gr. xx 1.3 Gm. 

Acid, carbol., gr. ]/§ .01 Gm. 

Glycerini, 1T\, XX 1.3 Cc. 

Aquse, . . f^iv 15. Cc. M. 

Every hour, in water. 

If the vomiting is so severe that no opportunity occurs for the 
medicament to come in contact with the gastric mucous membrane, 
an enema of chloral, gr. x-xv (0.6-1 Gm.), in some demulcent with 
tinctura opii deodorati, ttlx-xx (0.6-1.2 Cc), acts often like magic 
in quieting the distress of the tortured patient. 

The closer the case approaches the true cholera type, the more 
severe are the muscular cramps, and their treatment demanded. 
Prof. Da Costa suggests — 

R. Chloral, 3'iv 15. Gm. 

Ung. petrolei, ^j 30. Gm. M. 

To be rubbed over the affected muscles. 

Dr. Bartholow suggests — 

R . Chloral, giij 12. Gm. 

Morphinse sulph. , gr. iv .26 Gm. 

Aquae, f|j 30. Cc. M. . 

SlG. — Twenty minims, hypodermically, repeated p. r. n. 

Locally, sinapis, in the form of poultices of the dry powder, should 
be applied to the abdomen, or terebinthina stupes, or the hot-water bag. 

The after treatment depends upon the symptoms, generally an acid 
mixture and a regulated diet, with tonic doses of quinina sulphas, 
are indicated. 

ENTERO-COLITIS. 

Synonyms. Inflammatory diarrhoea ; ulcerative entero-colitis. 

Definition. A catarrhal inflammation of the lower portion of the 
small — ileum — and the upper portion of the large intestines, with a 
great tendency to ulceration of the intestinal glands if the catarrh 
becomes chronic ; characterized by moderate fever, nausea, vomiting, 
diarrhoea, swollen abdomen, pain, and emaciation. A common dis- 
ease of childhood. 

Causes. Improper and indigestible food ; summer temperature ; 
impure air; uncleanliness ; exposure to cold and damp air. 



116 PRACTICE OF MEDICINE. 

Most commonly a disease of childhood. 

Forms. Acute and chronic. 

Pathological Anatomy. Acute variety ; hyperemia, swelling, 
oedema, and softening of the mucous membrane of the lower portion 
of the small and the upper portion of the large intestines, with hyper- 
plasia of the intestinal follicles, their excretory follicles enlarged and 
tumid, readily distinguished as grayish or blackish points in the mid- 
dle of the glands ; the patches of Peyer are also enlarged, tumefied, 
and project above the level of the surrounding mucous membrane, 
the orifices of the follicles appearing as dark points ; these patches 
often have an ulcerated appearance, but upon closer examination 
ulcers are not discovered. 

Chronic variety ; the thickening and infiltration have extended to 
the submucous and muscular coats, followed by induration of the 
tissues, so that the walls of the intestines are often abnormally rigid. 
Ulceration occurs, which extends through the entire thickness of the 
membrane. "These ulcers, when isolated, are from one to one and 
a half lines in diameter, oval or circular in shape, and either have 
sharp-cut edges, as though the piece of mucous membrane had been 
cut out with a punch, or the mucous membrane bounding them is 
undermined." The small ulcers often coalesce, so that large, irregu- 
lar ulcerated patches are formed, having for their base the submucous 
or muscular coats, and have a grayish-white color. 

The mesenteric glands are enlarged, but seldom, if ever, undergo 
ulceration. 

Symptoms. Acute form ; may develop slowly, with restlessness 
and fretfulness, or suddenly with feveris hness, toss of appetite, thirst, 
nausea, moderate vomiting, and abdominal pain ; or diarrhoea may 
be the first indication of illness. Regardless of the character of the 
onset, the stools should present the characteristic appearance ; they are 
semi-fluid, heterogeneous, greenish, acid, mixed with yellowish frag- 
me7its of ordinary faeces, and undigested casein, termed the " chopped 
spinach " stools. The abdoinen is enlarged and tender. An irregular 
temperature record may occur with increased frequency of the pulse. 

Emaciatio7i is marked in proportion to the severity of the symp- 
toms ; in marked cases the child is reduced to a condition of the 
greatest debility within a few days.. 

Chro7iic form, or ulcerative entero-colitis, usually follows the acute 
form, the character of the symptoms being less severe, but decidedly 



DISEASES OF THE INTESTINAL CANAL. 117 

persistent : the strength fails, the temper is very irritable ; the com- 
plexion grows dark, sallow, and unhealthy, the skin dry and harsh, 
and, in consequence of the marked emaciation, either hangs in folds 
around the shrunken limbs or is drawn tightly over the joints*; the 
abdomen is enlarged and tender, the stools numbering from six to a 
dozen during the day and night, consisting of the products of an im- 
perfect digestion mixed with mucus, serum, pus, and oftentimes blood, 
having a semi-fluid consistency, and an extremely offensive odor. 
Ulcerative stomatitis is a frequent complication adding to the dis- 
comfort of the patient. An irregular temperature record may occur 
with increased frequency of the pulse. 

Duration. Acute form, from ten days to about two weeks, sub- 
siding gradually ; chronic form, from one to two or three months, or 
even longer. 

Diagnosis. The acute form can hardly be mistaken for any 
other condition, if the characteristic stools and other abdominal symp- 
toms are present. The chronic form has been frequently mistaken 
for the diarrhoea of tuberculosis, an error that can hardly occur if a 
physical examination of the chest has been made, as well as micro- 
scopical examination of the stools. 

Prognosis. Always a very serious malady, and proves fatal if it 
attacks the weak during midsummer, or when surrounded by unfavor- 
able hygienic conditions ; in vigorous children, who have passed 
through their first dentition, the prognosis is quite favorable. 

Treatment. For the acute form, restricting the amount of food 
for the first few days is of importance. Fresh, pure air, cleanliness, 
and rest are also of great importance. 

Any one of the following formulae may be used with advantage : 

R. Salol, gr. ij .13 Gm. 

Bismuthi subnit., gr. v .32 Gm. 

Ft. chart. 

SiG. — Such a powder every two hours. 

Or— 

%. . Hydrargyri chlor. mite, . . . . gr. ss .032 Gm. 

Pulv. ipecac. , gr. ss .032 Gm. 

Pulv. opii, gr. ss .032 Gm. 

Crete prseparat , gr. xx 1. 3 Gm. M. 

Ft. chart. No. xij. 

SiG. — One every two or three hours, to child of one year. 

Many cases do well with pulvis kino comp., others with minute 



118 PRACTICE OF MEDICINE. 

doses, frequently repeated, of acidum lacticu?n, and many others with 
bismuthi subniiras , gr. x-xv (0.6-1 Gm.), in milk, every few hours. 

The following is a good combination : 

R. 'Bismuthi subnit., ^iij 12. Gm. 

Tinct. kino, f 5iss 45. Cc. 

Tinct. opii camphorat., . . . . f Jiss 45. Cc. 

Mist, cretse, ^ iij 90. Cc. M. 

SiG. — Tablespoonful every few hours. 

Locally, warmth to the abdomen, with mustard, turpentine stupes, 
or the spice poultice, made as follows : cloves, allspice, cinnamon, and 
anise seeds, each half an ounce (15.6 Gm.), pounded (not powdered) 
in a mortar, and placed between two pieces of coarse flannel about 
six inches square and quilted in ; soak this for a few minutes in hot 
brandy or hot whisky and water, equal parts, and apply to the abdo- 
men, heating again as it becomes cool. 

Chronic entero-colitis. Few conditions will tax the skill and 
patience of the physician to the same degree. 

First and foremost the diet must be carefully regulated. Milk 
alone, or predigested, or with lime-water, in the majority of cases is the 
best article of diet. Should it disagree, then recourse must be had to 
some of the prepared foods, such as Mellin's, Horlick's, Ridge's, 
Blair's prepared wheat, Liquid Peptonoids, or Eskay's albuminized 
food, or other prepared foods, often the one agreeing with one 
patient will not agree with another. 

After caring for the diet, then the hygiene of the patient requires 
attention. Cleanliness, such as daily warm baths, often adding with 
advantage sea-salt. Rest in bed for an hour or more after meals if 
the patient cannot be kept continually in bed. The air of the room 
should be fresh and pure. 

Among drugs may be mentioned bisfmithum and pepsinum or sali- 
cinum. Or — 

\i . Argenti nitrat., gr. j .065 Gm. 

Acid, nitric, dil. rr^xv 1. Cc. 

Mucil. acacire, f,^ ss l S- Cc. 

Aq. cinnamomi, ad f^iij ad 90. Cc. M. 

Sig. — Teaspoonful, diluted, every three or four hours. 
Or— 

R. Acidi carbolici, gr. T \,-l .005-. 008 Gm. 

Tincturae iodi, Iir\j— ij ' .06-. 12 Cc. 

Aquae menthae, f ~j 4. Cc. M. 

Si<;. — Every three or four hours. 



DISEASES OF THE INTESTINAL CANAL. 119 

Or— 

R. Tinct. calumbae, f^iij I2 - Cc. 

Liq. ferri nitratis, Ttlxxx 2. Cc. 

Syrupi zingib. , .... q. s. adf^iij ad 90. Cc. M. 

SiG. — One or two teaspoonfuls, according to age, every three or four 
hours, diluted. 

Or— 

R. Quininae muriat. , gr. xxv 1.6 Gm. 

Acid, tannici, gr. x .6 Gm. 

Syr. limonis, f 3 ij 8. Cc. 

Aq. chloroformi, ad f 3 iij ad 12. Cc. M. 

Sig. — Teaspoonful every two hours. 



CHOLERA INFANTUM. 

Synonyms. Choleriform diarrhoea ; summer complaint. 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the stomach and intestines, together with an irritation 
of the sympathetic nervous system, occurring in children during their 
first dentition ; characterized by severe colicky pains, vomiting, purg- 
ing, febrile reaction, and prostration. 

Cause. Age. There is no other disease of the intestinal canal 
showing the evidence of infectious origin so strongly as typical attacks 
of cholera infantum. Bad hygiene, or, as it is now entitled, "civic 
malaria"; continuous high temperature ; improper food ; dentition; 
constitutional, as in the feeble, delicate, nervous, or irritable. 

Pathological Anatomy. Resembles closely, if not identical 
with, the phenomena of catarrhal gastritis and enteritis, together with 
a powerful irritation of the fibres of the sympathetic nervous system. 

Symptoms. The onset is sudden in a child previously well, or 
in a child suffering from a bowel affection. 

Begins with vomiting, purging, abdominal pain, fever, rapid pulse, 
and intense thirst. 

The vomited matter is partly digested food, sero-mucus, and finally 
bilious, and is accompanied with distressing retching. The thirst is 
a marked phenomenon of the disease, and ice and water will be 
taken incessantly, although rejected only a few moments after. 

The stools are first partly faecal, but soon watery or serous, soaking 



]20 PRACTICE OF MEDICINE. 

the clothing, leaving a faint greenish or yellowish stain ; their odor 
is musty, at times fetid ; their number is from ten to twenty in the 
day. Pains precede the vomiting and purging, colicky in char- 
acter. 

The fever begins at once, the temperature varying from ioi°to 105 , 
with morning remissions. The pulse is rapid and feeble, ranging 
from 130 to 160 beats. 

These symptoms continue but a few hours, before rapid wasting 
ensues, the body shrinks, the eyes are sunken and partly closed, the 
mouth partly open, the lips dry, cracked, and bleeding. The child, 
at first irritable and restless, passes into a semi-comatose condition, 
the pulse becoming more and more feeble ; the surface has a clammy 
coldness, the contracted pupils not responding to light, and the 
stupor deepens, death soon following, or the symptoms slowly ame- 
liorate, convalescence being slow and tedious. 

Diagnosis. The entero- colitis or inflammatory diarrhoea of child- 
hood is constantly being mistaken for cholera infantum. The symp- 
toms of the former are : gradual onset, with frelfulness, loss of appe- 
tite,, feverishness, nausea, and moderate vomiting, soon followed by 
diarrhoea, the stools being semi-fluid, greenish, mixed with yellowish 
particles of faeces and undigested casein, with a sour odor, the 
"chopped spinach" stools, the abdomen distended and tender, 
moderate fever and thirst, and having a duratio?i of about two weeks. 

Prognosis. Difficult to predict the result, and so care must be 
exercised in giving a prognosis. The duration of the choleraic symp- 
toms is short, under five days, but relapses are common, and the 
sequelae are protracted. 

Treatment. — The result of any mode of treatment for true cases 
of cholera infantum is unsatisfactory. Holt urges attention to the 
toxic nature of the disease, and suggests following indications for 
treatment : Empty stomach and intestines by stomach washing and 
intestinal irrigation ; neutralize the cardiac and nervous poison by 
hypodermics of morphia and atropia ; supply the fluid drain by 
hypodermoclysis of normal salt solution, and its intestinal use, and 
reduction of temperature by the graduated cooling bath and ice-cap to 
the head and bold stimulation. Change of air of the greatest benefit. 
Restricted diet, and particularly for first few days, using brandy, TT^v-x 
(0.3-0.6 Cc), in barley water at hourly intervals. 

For the vomiting, large doses of bismuthum ; or chlotal, gr. j-iij 



DISEASES OF THE INTESTINAL CANAL. 121 

(0.065-0.21 Gm.), by mouth in demulcent, or double the amount by 
the rectum, or one of the following : 

R • Bismuth, subnit. , 5jij 8. Gm. 

Acid, carbolici, gr. j .065 Gm. 

Mist, acaciae, 

Aq. menth. pip., aa f t ^j aa 30. Cc. M. 

SlG. — Teaspoonful every half-hour, hour, or two hours. 

Or^- 

R . Hydrargyri chlor. mit, . . . gr. 2V - 00 3 Gm. 

Bismuth, subnit., gr. ij-v -^--S Gm. M. 

SlG. — A powder every half hour. 

Good results are reported from bismuthi salicylas, gr. ij (0.13 Gm), 
with sugar of milk every hour or two, or salol, gr. j-ij (o 065-0.13 Gm.), 
every two or four hours. 

If the fever is high, sponging with alcohol and water, the cold 
pack, or the cool bath can be used first, gradually reducing its tem- 
perature, and afterwards using stimulants. 

For degression, regulated nursing, and feeding every two hours, and 
water or ice to quench the intense thirst, and cognac brandy, tt\,v-x 
(0.3-0.6 Cc), every hour or two, in water, by mouth or in warm 
enema. 

Locally : over epigastrium, mustard or a spice poultice, or turpen- 
tine stupes. 

If the nervous symptoms become aggravated, small dose of potassii 
bromidum or valerian, which " reduces the reflex excitability, motil- 
ity, and sensibility," is indicated. 



ACUTE DYSENTERY. 

Synonyms. Colitis ; ulcerative colitis ; bloody flux. 

Definition. An acute inflammation of the mucous membrane of 
the large intestines ; either catarrhal or croupous in character, followed 
in some cases with ulceration, characterized by fever, tormina, tenes- 
mus, and frequent, small, mucous, and bloody stools. 

It occurs either sporadically, endemically , or epidemically. 

Four clinical forms are described : acute catarrhal ; amcebic or 
tropica] ; croupous or diphtheritic ; chronic dysentery. 
II 



122 PRACTICE OF MEDICINE. 

Causes. Sporadic, endemic, or catarrhal dysentery prevails most 
extensively in the summer and early autumn months. All forms of 
colitis are of bacterial origin. Sudden atmospheric changes, such as 
hot days and cool nights. Malaria has some connection with its 
causation. Errors in diet not a cause. The drinking water may be 
the means by which the poison gains entrance to the system. 

Amoebic or tropical dysentery, characterized by the presence in the 
stools of the Amceba coli (Losch) or Amoeba dysenterica (Councilman 
and Lafleur). This variety is often epidemic in the tropics. 

Croupous or diphtheritic 'dysentery is often epidemic ; frequently 
occurs as a terminal event in acute and chronic diseases. The causes 
are much those of the acute catarrhal form, acting upon a depressed 
system. The Amoeba coli may be seen in the stools. 

Dysentery is not contagious, but is infectious. 

Pathological Anatomy. Catarrhal dysentery ; congestion, 
swelling, and oedema of the mucous membrane and submucous 
tissue of the large bowel, with an over-production of mucus ; the fol- 
licles are enlarged, from retention of their contents, the result of the 
swelling ; the congested vessels often rupture ; the mucous mem- 
brane softens in patches, and is detached, forming ulcers. Recovery 
follows, if the destruction of tissue is small, smooth cicatrices, minus 
gland structure, marking the site. 

Amoebic or tropical dysentery, the lesions are also in the large intes- 
tines and sometimes in the lower portion of the ileum. Abscess of 
the liver is a frequent complication. 

"The lesions consist of ulceration, produced by preceding infiltra- 
tion, general or local, of the submucosa, the general infiltration being 
due to an oedematous condition, the local to multiplication of the 
fixed cells of the tissue. In the earliest stages these local infiltrations 
appear as hemispherical elevations above the general level of the 
mucosa. The mucous membrane over these soon become necrotic 
and is cast off, exposing the infiltrated submucous tissue as a 
grayish-yellow, gelatinous mass, which at first forms the floor of the 
ulcer, but is subsequently cast off as a slough." (Osier.) 

Croupous or diphtheritic dysentery begins with intense congestion, 
swelling, and oedema of the mucous and submucous tissue, with 
extravasations of blood and the whole mucous membrane covered 
with a firm, fibrinous exudation ; the mucous membrane softens and 
sloughs, leaving large ulcers and gangrenous spots. If recovery 



DISEASES OF THE INTESTINAL CANAL. 123 

occur, large cicatrices form, which narrow the calibre of the intestinal 
tube. 

The mesenteric glands enlarge, soften, and abscesses form in them ; 
the liver becomes the seat of small abscesses, from embolic obstruc- 
tion of the radicles of the portal vein ; the heart muscles are flabby 
and more or less fatty. 

Symptoms. Catarrhal form begins gradually, with diarrhoea, 
loss of appetite, nausea, and very slight fever, which continues for 
two or three days, when the true dysenteric symptoms develop, to wit, 
pain on pressure along the transverse and descending colon, tormina 
or colicky pains about the umbilicus, burning pain in the rectum, with 
the sensation of the presence of a foreign body and a constant desire 
to expel it, or tenesmus ; the stools for the first day or two contain 
more or less faecal matter, but they soon change to a grayish, 
tough, transparent mucus, containing more or less blood and pus ; 
during the tormina, nausea and vomiting may occur; the urine is 
scanty and high-colored ; the number of stools varies from five to 
twenty or more in the twenty-four hours. 

The duration is about one week, the patient being much emaciated 
and enfeebled. 

Amoebic form begins gradually as the catarrhal form, or gradually as 
an increasing diarrhoea. Soon the stools become characteristic of the 
variety of the attack, being frequent, bloody, mucoid, but very fluid ; 
as the disease progresses, the stools become yellowish-gray and liquid, 
containing mucus, sometimes bloody. The number of stools varies 
from six to a dozen or more in a day. Actively moving amcebce are 
found in the stools, disappearing as the stools become formed. Fever 
may or may not be present, or may come and go. Abdominal 
pain and tenesmus are present in the majority of cases. 

The loss of flesh and strength is marked. Abscess of liver and 
lungs are frequent and grave complications. 

Duration from six to twelve weeks ; recovery tedious, owing to anae- 
mia and loss of flesh. 

In every endemic or epidemic of dysentery a number of amoebic 
cases will occur. During the past three years I have seen probably 
two hundred cases of dysentery, beginning as catarrhal, but in the 
midst of the endemic a number of amoebic cases occurred, the con- 
valescence long outlasting the catarrhal variety. 

The croupous or diphtheritic form sets in suddenly, the stools being 



124 PRACTICE OF MEDICINE. 

more frequent, containing more blood and pus, with patches of mem- 
brane, even casts of the bowel, together with more or less gangrenous 
mucous membrane ; nausea, vomiting, and great prostration, cold 
skin, feeble pulse, and emaciation with anxious expression, the odor 
surrounding the patient being fetid. 

The occurrence of this form as a termination of Bright's disease, 
lung and heart diseases, must be borne in mind. 

The duration of the grave symptoms is three or four days, when 
collapse and death occur, or slow convalescence begins, continuing 
for weeks. 

Chronic Dysentery. This is really a continuation of the acute 
disease, the symptoms continuing the result of the ulcerated mucous 
membrane, or the cystic degeneration of the glandular elements of 
the large gut (Woodward). Rarely, dysentery develops subacutely, 
and thus is almost chronic from the beginning. There is seldom a 
characteristic stool, little colicky pain, and little or no tenesmus, but a 
progressive loss of flesh with loose bowels, the stools containing mucus, 
little or no blood, undigested food, and are frothy. The number varies 
from two to a dozen in a day. Acute exacerbations are frequent. 
Duration, often months or years. 

Complications. Peritonitis ; hepatic abscesses ; phlebitis of the 
intestinal veins ; -intestinal perforation. 

Diagnosis. Enteritis lacks the tenesmus and characteristic stools. 

Peritonitis, when idiopathic, shows higher temperature, greater 
tenderness, and constipation. 

Chronic dysentery is difficult to distinguish from chronic diarrhoea. 

Prognosis. Catarrhal form favorable, save in those debilitated. 

Amoebic form : the mortality is higher than in catarrhal form, and 
in favorable cases the convalescence is slow. 

Croupous form: the prognosis is always grave, for if recovery does 
occur, the bowel may be crippled from loss of structure, or from nar- 
rowing of its calibre, the results of cicatrices. 

Treatment. Keeping in mind the following dictum of Osier, 
no case of dysentery, however mild, should be lightly considered : 
" Dysentery is one of the four great epidemic diseases of the world. 
In the tropics it destroys more lives than cholera, and it has been 
more fatal to armies than powder and shot." 

The patient should be confined to bed in even the mildest attack, 
and the stools removed at once and disinfected. In fact, the bed-pan 



DISEASES OF THE INTESTINAL CANAL. 125 

or other vessels should constantly contain a solution of ferrous sul- 
phate (copperas) sufficient to cover the expected stool. 

The diet to be of the most nourishing yet bland character, adding 
stimulants if much prostration. 

The most frequently used drug, and in many cases by far the best, 
is opium, alone or combined with one or more astringents : 

R . Ext. opii, gr. ss .032 Gm. 

Plurubi acetat., gr. ij .13 Gm. 

Every two hours. 

Or— 

R . Pulv. opii, gr. ss .032 Gm. 

Plumbi acetat., gr. ij .13 Gm. 

Pulv. ipecac, g r - X ,01 ^ Gm. 

Every two hours, until character of stools change. 

I have frequently seen the character of the stools change within 
twenty-four hours with the following, which I call Mistura enteric a, 
viz. : 

R. Acid, sulph. dil., f g ss 15. Cc. 

Tinct. opii deodorat, f t ^j 30. Cc. 

Spts. camphorae, f^j 30. Cc. 

Tinct. capsici, f<f ss I S- Cc 

Spts. chloroformi, f§ ss I 5- Cc. 

Spts. vini gallici, f Jiss 45. Cc. 

SlG. — One teaspoonful every two or three hours, diluted. 

In more than one instance I have seen a severe attack of acute 
dysentery succumb to morphincz sulphas, gr. %-}i (0.016-0.032 Gm.), 
three or four times daily hypodermically, within three or four days. 
For the intense tormina and tenesmus no remedy is comparable with 
morphia by the hypodermic method. 

In strong young individuals the very best prescription possible is — 

R . Magnesii sulph , ^j 4. Gm. 

Acid, sulph. dil., ........ TT^x .6 Cc. 

Tinct. opii deodorat. , TT^x .6 Cc. 

Aquae chloroformi, .... ad 3 ij ad 8. Cc. M. 

Every two or three hours, until faeces appear in the stools, when 
small doses of opium and quinince sulphas may be used. 

Bismuthi subnit., gr. xxx (2 Gm.), every two or three hours, or 



126 PRACTICE OF MEDICINE. 

bismuthi salicylas, gr. xx (1.3 Gm.), every two or three hours, are often 
successful. 

Dr. Loomis speaks strongly of ipecacuanha, gr. % (0.016 Gm.), 
every half-hour, with sufficient opium to secure quietness. The 
large doses of ipecacuanha recommended I have had no experience 
with. 

Ringer recommends hydrargyri chloridum corrosivu?n, gr. T ^ 
(0.00065 Gm.), every hour or two, which " rarely fajls to free the 
stools from blood and slime, although in some cases a diarrhoea of a 
different character may continue for a short time longer." 

In children the following combination is successful : 

R. Pulv. ipecacuanhse, g r - X * - ol ^ Gm. 

Bismuth, subnit., gr. v-x .32-. 65 Gm. 

Cretse praep., gr. iij .2 Gm. M. 

SiG. — Every two hours. 

Washing out the rectum with either tepid, hot, cold, or iced water, 
as suggested by Prof. Da Costa, adds greatly to the patient's comfort 
and to the decrease of the inflammatory process. Ice suppositories 
are soothing and relieve the tenesmus and rectal pain. 

A one or two per cent, solution of creolin (one-half pint) as an 
enema often rapidly lessens the number of stools and the tenesmus. 
Dr. H. C. Wood recommends iodoform suppositories. 

" In the cases of amoebic dysentery we have been using at the 
Johns Hopkins Hospital, with great benefit, warm injections of quinine 
in strength of 1 to 5000, 1 to 2500, and 1 to 1000. The amoebae are 
rapidly destroyed by it." (Osier.) 

I have met over five hundred cases of acute dysentery during the 
past six years, and have nearly always been successful with nuclein- 
Aulde, gr. j (0.065 Gm.), or rr^j-v (0.06-0.3 Cc), every hour until 
the character of the stools change, when the interval of the dose is 
widened to two or three hours and bismuthum or the foregoing 
mistura enterica added. 

Locally, poultices, stupes, and the water bag do no good, but if 
they are agreeable to the patient they may be allowed, as they do 
no harm. 

Chronic dysentery. A carefully selected but nourishing diet, change 
of scene, and some of the following remedies : Bismuthum subnitrat., 
gr. xxx (2 Gm.), t. i. d. ; terebinthina, rr^x (0.6 Cc), every three or four 



DISEASES OF THE INTESTINAL CANAL. 127 

hours; argenti nitras, gr. x /%-yi (0.008-0.022 Gm.), three or four times 
daily ; or R . Cupri sulphas, gr. ye (0.01 1 Gm.) ; ext. opii, aq., gr. %-Yz 
(0.016-0.032 Gm.) ; ext. nucis vomica, gr. yi (o.ou Gm.), in pill, four 
times daily. 

Chronic dysentery is sometimes protracted by a trifling patch of in- 
flammation or ulceration in the rectum or sigmoid flexure, or a relaxed 
condition of the mucous membrane of the rectum, and of the hemor- 
rhoidal vessels. There occur two or three loose stools in the morn- 
ing, a mucous dysentery, and then a comparatively comfortable day. 
The stools are preceded by some colicky pain across the lower part 
of the abdomen and in the line of the large bowel. The general 
condition, other than the anaemia and weakness, of the patient is 
good. Drugs by the mouth are useless to control these cases ; the 
medication must be made directly to the diseased part. Injections of 
argenti nitras, gr. v to xx or xxx (0.32-1.3-2 Gm.), to the pint, are 
curative ; the silver may be combined with opium (R. Argent, nitrat., 
gr. j (0.065 Gm.); tinct. opii deodorat., TTlxv (i Cc.) ; aquae amyli, 
fgiv (120 Cc.) ; M.). 

During the convalescence from all varieties of dysentery, tonics 
are indicated (R. Strychninae sulph., gr. y 2 (0.032 Gm.) ; acid hydro- 
chlorici dil., f^ij (8 Cc.) ; tinct. gentian comp., q. s. ad f^iv (120 
Cc.) ; M. S. — One teaspoonful before meals in water. A course 
of oleum morrhutz with syr. calcii lactophosphatis, should be used 
if much emaciation. 



TYPHLITIS. 

Synonyms. Inflammation of the caecum ; typhlitis stercoralis. 

Definition. A catarrhal inflammation of the mucous membrane 
of the caecum and ascending colon ; characterized by pain, tender- 
ness, constipation, and in certain cases a characteristic vomiting. 

Causes. I do not believe the term " typhlitis " is to be sup- 
planted by the term appendicitis ; I am convinced there are two 
conditions having some symptoms in common. In a majority of 
instances typhlitis is niechanical, due to the accumulation of faeces 
in the caecum. 

Pathological Anatomy. Similar to the catarrhal inflammation 
of dysentery. 

Symptoms. Pain and tenderness in the right iliac fossa and 



128 PRACTICE OF MEDICINE. 

along the ascending colon, with some pominence of this region ; the 
bowels are distended with gas {meteorism) and are usually consti- 
pated, or small liquid stools may occur from time to time, due to the 
accumulation of hardened faeces in the sacculated periphery of the 
caecum, leaving a central canal through which the liquid contents of 
the upper bowel can pass. 

In severe cases, " the local pain, tenderness, and swelling are 
greater; there are impaction of fceces and no movements or flatus. 
There are decided fever, restlessness, and also nausea and vomiting. 
The vomited matters, at first the contents of the stomach, then of 
the duodenum, with bilious matter, and ultimately, if the impaction 
persists, of material having the odor of faeces. With these symp- 
toms occur great depression of the vital powers. Peritonitis is 
finally developed by contiguity of tissue or by rupture of the 
bowel." 

The temperature in even mild cases is one or two degrees above 
the normal and in a fair number an eruption is seen upon the 
abdomen, consisting of one or two dark-red spots the size of a pin- 
head, which are of short life and disappear on pressure. 

Duration. The mild form lasts about one week. The severe 
form may terminate in subacute peritonitis, continuing about two 
weeks. 

Diagnosis. The mild form is distinguished from other intestinal 
affections by the localized pain, tenderness, and prominence, and the 
constipation. 

The severe form can only be distinguished from the other forms of 
intestinal obstructio?i by the history of the case and attack, and the 
results of treatment. 

Prognosis. Mild form favorable. Severe form grave, although 
not necessarily fatal. 

Treatment. The patient should be kept in bed, and placed on a 
strictly milk diet in very limited amounts. 

Two indications are to be met, which are seemingly opposed to each 
other : first, the removal of the.accumulation of faeces, which in the 
majority of cases has caused and still maintains the inflammation ; 
second, to retard the inflammation resulting from the presence of the 
fecal mass. 

If the pain and suffering be intense, at once administer a hypo- 
dermic injection of morphince sulphas. 



DISEASES OF THE INTESTINAL CANAL. 129 

The two indications above named are met by the use of the fol- 
lowing : 

R. Magnesii sulph., % xij 48. Gm. 

Acid, sulphurici dil., . . . . fgij 8. Cc. 

Tinct. opii deodorat., . . . .f^iv 15. Cc. 

Spts. chloroformi, fgij 8. Cc. 

Aquae menth. pip. , . . q. s. ad f^ iij ad 90. Cc. M. 
SiG. — One teaspoonful every hour, diluted. 

If it be true that calomel has a specific action upon the lower por- 
tion of the small bowel, increasing the secretion from the glands 
located there, then the following should be useful : 

R . Hydrargyri chlor. mite, . . . gr. ij . 13 Gm. 

Sodii bicarb., gr. xx 1. 3 Gm. 

Sacc. lac, gr. xxx 2. Gm. 

Ft. chart. No. x. 

Sig. — One every hour till twelve taken, followed by hot Hunyadi Janos 
water or other saline purgatives. 

In severe cases, begin an opium influence at once, by hypodermic in- 
jections of inorphincB sulphas guarded with atropines sulphas, con- 
tinued until all symptoms of inflammation have subsided, when 
attempts to remove the accumulated faeces may be made by irriga- 
tion of the bowel with warm soapsuds, and the cautious administra- 
tion of magnesii sulphas in drachm doses, every two hours. 

Locally, hot, dry applications, or the ice bag. 



PERITYPHLITIS— APPENDICITIS. 

Synonyms. Perityphlitic abscess ; suppurative appendicitis ; 
pericecal abscess ; iliac abscess. 

Definition. Perityphlitis ; an acute inflammation of the connec- 
tive tissue around the caecum (with localized peritonitis) leading to 
the formation of an abscess. 

Appendicitis. An acute or subacute inflammation of the appendix 
vermiformis, involving the surrounding tissues (with a localized 
peritonitis), leading to perforation of the appendix and the develop- 
ment of an abscess. 

Causes. The frequency with which appendicitis is met with has 
12 



130 PRACTICE OF MEDICINE. 

led to the belief that the condition is of germ origin, the exact nature 
of which not having been determined. The great majority of cases 
of perityphlitis are secondary to inflammation of or perforation of the 
vermiform appendix — appendicitis. Have seen two cases of true 
perityphlitis, the result of exposure to cold and wet. 

Appendicitis may result from the presence of a foreign body in 
its canal, consisting of inspissated faecal masses, which, becoming 
incrusted with lime salts, are termed " faecal calculi," and becoming 
rounded in shape closely resemble a cherry-stone, for which they 
have been mistaken. Foreign bodies, particularly seeds of fruit, 
sometimes, but not so often as is believed by the laity, gain access 
to the appendix and produce inflammation leading to perforation. 
Torsion of the appendix is also among the infrequent causes. The 
disease is more common in males than females. Occurs most fre- 
quently between the ages of ten years and thirty years. Relapses 
are fairly frequent in cases not progressing to perforation. 

Some one has suggested the increased frequency of appendicitis 
since the reappearance of influenza. 

Symptoms. The symptoms of the two conditions are much 
alike; begins with a feeling of weight, soreness, and rapidly develop- 
ing and severe pain in the lower right abdomen (McBurney's point), 
accompanied with nausea and vomiting. The pain is increased by 
lying on the left side ; the right leg is flexed, the abdomen becomes 
tense, prominent, and tender, with the progressive development of a 
hard swelling in the right iliac region. The temperature at the onset 
is from 90°-ioo°, and may or may not be preceded by a chill; the 
pulse 80, full and strong ; the tongue coated with red tips, the bowels 
costive. In addition to the persistent, localized pain, occurs severe 
colicky paroxysms, which may shoot into the hip and thigh. The 
expression of the patient is pinched and denotes suffering. The 
special tendency of the disease is toward suppuration, which is an- 
nounced by irregular chills, feverishness, the temperature shooting 
suddenly to ioi°-io3°, and sweats ; and a feeling of tefision and 
throbbing. Its development is slow, and if associated with typhlitis 
the symptoms of that affection are added. 

Complications. Perforation of the appendix. Local or general 
peritonitis. 

Diagnosis. Differs from typhlitis by the absence of the colicky 
pains, dyspeptic symptoms, costive bowels, and tympanites preceding 



DISEASES OF THE INTESTINAL CANAL. 131 

the development of a tumor; in perityphlitis the tumor \b present with 
the development of the symptoms. 

Psoas abscess is not associated with intestinal symptoms, and the 
discharge is free from a faecal odor. Renal and ovarian tumors should 
not be sources of error. The possibility of hernial tumors must not 
be overlooked. 

Treatment. If not associated with typhlitis, the treatment is to 
allay the inflammation in the first stage, by either ice, locally, or freely 
painting with tinctura iodi ; if suppuration is evident, surgical meas- 
ures are the indication, medical treatment endangering life. 



PROCTITIS. 

Synonyms. Catarrh of the rectum ; dysentery ; rectitis. 

Definition. A catarrhal inflammation of the mucous membrane 
of the rectum and anus ; characterized by pain, tenesmus, and fre- 
quent stools of hardened faeces, or of mucus, pus, and blood. 

Causes. Chief cause, constipation ; also sitting on damp ground 
or stone steps ; habitual use of enemata or purgatives ; diseases of 
the liver; hemorrhoids. 

Pathological Anatomy. Similar to those occurring in catar- 
rhal dysentery. 

Symptoms. Uneasy sensation and burning in the rectum, with 
a constant desire for stool, or tenesmus ; often so severe as to cause a 
prolapse of the mucous membrane. The stools may be either hard- 
ened faces or scybala from the distended colon, which cause intense 
pain when they reach the rectum ; or the stools may be of mucus, 
?nuco-pus, or bloody or blood-streaked. Generally there are present 
nausea, especially during the tenesmus, headache, feverishness, and 
malaise. In severe cases there is strangury, and, with the tenesmus, 
straining with urination. 

If the case be protracted and severe, inflammation of the connec- 
tive tissue around the rectum occurs, causing periproctitis, which 
usually terminates in various kinds of fistulae. 

Complications. Periproctitis ; peritonitis ; hepatic abscesses. 

Diagnosis. In males, the disease cannot be confounded with any 
other affection, save, perhaps, hemorrhoids. In females, displace- 
ments of the uterus may somewhat simulate the symptoms of proctitis. 



132 PRACTICE OF MEDICINE. 

Prognosis. Uncomplicated cases favorable. Either of the com- 
plications adds greatly to the gravity of the affection. 

Treatment. In cases due to constipation the chief indication is 
to empty the bowels, using an enema *of warm water and soap or 

magnesii sulphas : 

H- Magnesii sulph., t ^ij 60. Gm. 

Glycerini, . f Jss 15. Cc. 

Aquae bul., f^i y I2 °- Cc. M. 

Irrigation of the bowel with warm water once or twice daily assists 
in the liquefaction of the hardened faeces. Either enemata or sup- 
positories of glycerinum should answer in certain cases. 

Cases other than those due to constipation, emollient enemata and 
opium, one of the best being — 

R. 01. olivae, fgij 60. Cc. 

Tinct. opii deodorat., tt\,xv 1. Cc. 

The use of hot injections of an astringent character, such as hot, 
strong black coffee, from half-pint to quart, as hot as will be tolerated 
by the rectum, as suggested by Dr. Pepper, is valuable in cases of 
irritable rectum with a disposition to looseness. In cases not bene- 
fited by the hot injections, relief may follow the use of injections of 
water, say two ounces, as cold as can be borne without chilling, 
administered at bedtime, having it retained. 

If symptoms of periproctitis occur, use ice to the parts, and if sup- 
puration ensue, evacuation by a free opening and quinines sulphas. 



INTESTINAL OBSTRUCTION. 

Synonyms. Intestinal occlusion; strangulated hernia; invagi- 
nation ; intestinal stricture ; ileus. 

Definition. A sudden or gradual closure of the intestinal canal; 
characterized by pain, nausea, vomiting, constipation, and finally col- 
lapse. 

Causes. The numerous causes are arranged as follows : 

1. Accumulations within the bowel of hardened faeces, or foreign 
bodies. 

2. Strictures the result of cancer, ulceration, or cicatrices. 

3. Pressure against the bowel, from peritoneal adhesions, tumors, 
and abnormal growths. 



DISEASES OF THE INTESTINAL CANAL. 133 

4. Strangulations, due to the numerous forms of hernia. 

5. Invagination or intussusception, the most common. 

6. Twisting, volvulus or rotation of the bowel. 
Pathological Anatomy. Invagination is the form calling for 

special description here. It is usually caused by the lower portion of 
the ileum slipping down into the caecum, as the finger of a glove 
might be invaginated, causing thus an actual mechanical obstruction ; 
this is produced by a spasm of the ileum, whereby its calibre is greatly 
diminished, thus permitting its descent into the lower bowel. Result- 
ing from this occlusion or compression, are congestion, inflammation, 
with secondary constitutional reaction and death, or more rarely the 
invaginated bowel sloughs off and is voided by stool, union taking 
place at its site and recovery following. 

Symptoms. The onset of the symptoms may be either sudden 
ox gradual, and are as follows : 

Constipation, with more or less severe colicky pains, not relieved by 
either purgatives or injections ; feeling of weight and soreness, with 
distention of the abdomen from retained gas, and nausea and vomit- 
ing ; the symptoms all grow more pronounced, the pain becoming 
violent, tenderness in limited areas, the vomiting becoming stercorace- 
ous, the abdomen hard and tense, the eyes sunken, the pulse quick 
and feeble, the skin cold and covered with a clammy sweat. Absence 
of escaping flatus is a valuable diagnostic symptom. The above con- 
tinue more or less pronounced for a week or ten days, when collapse 
and death occur, or more rarely there is a gradual return to health. 

Cases occur rarely in which small, faecal, muco-purulent stools con- 
taining more or less blood exist, instead of constipation. 

Diagnosis. One of the most difficult, and can only be solved by 
a careful study of the case along with the different causes producing 
the affection. The sight of the occlusion can rarely be determined 
positively, unless the X-ray he successful. 

Intestinal obstruction may be mistaken for intestinal colic, hernia, 
enteritis, peritonitis, hepatic or renal colic. 

Prognosis. Always grave, but guided by the cause. Impacted 
faces favorable. Invagination less favorable, but recoveries occur ; 
the longer the symptoms continue, the more favorable the outlook. 
Strangulations unfavorable, but many recoveries recorded. Strictures 
due to cancer, cicatrized ulcers, and the like, are the most unfavorable. 

Treatment. Stop all forms of purgatives as soon as the diagno- 
sis of obstruction is determined. 



134 PRACTICE OF MEDICINE. 

Opium is indicated in all forms with pain, and is best administered 
in the form of morphines sulphas, combined with small doses of 
atropines sulphas, hypodermically. 

The author has seen the most brilliant results follow the plan of 
washing out the stomach as suggested by Kiissmaul, and with full 
doses of atropines sulphas hypodermically, for its action on intestinal 
peristalsis, and with electricity, one pole oyer abdomen, the other in 
rectum. 

Cases resulting from impacted faeces are rapidly cured by the above 
plan combined with irrigation of the lower bowels with tepid soap- 
suds or a high enema of glycerinum and magnesii sulphas. 

If invagination, raising the buttocks and lowering the chest, and 
repeated injections of warmed oil, are recommended, or have the 
abdomen opened and the invagination reduced. 

Distention of the bowel by pumping air through long rectal tubes, 
or disengaging carbonic acid gas in the bowel, by first injecting a solu- 
tion of sodii bicarbonas, and follow this with a solution of acidum tar- 
taricum, about one drachm (4 Gm.) of each, pressure being made 
against the anus to prevent escape ; but the danger of rupture of the 
bowel must not be overlooked. 

Flatulent distentio?i can be removed by the long aspirator needle. 

Laparotomy 'is no doubt the operation of the future, when our means 
of diagnosticating the location of the trouble is more exact. 

The nutrition of the patient is best attained by injections of either 
peptonized foods or defibrinated blood, or both. 



INTESTINAL PARASITES. 



TAPEWORMS. 

Varieties. Teenia solium; Tcenia saginata ; Bothriocephalus 
latus. 

Causes. The Ternia solium, the " armed tapeworm," is the most 
common in this country. It is derived from the embryos contained 
in pork, known as the cysticercus cellulosus. 



INTESTINAL PARASITES. 135 

The Tcenia saginata, the "unarmed tapeworm," a not uncommon 
variety, is derived from the embryos contained in beef, known as 
cysticercus bovis. 

The Bothriocephalus latus, also an "unarmed tapeworm," the 
largest parasite infesting man, is supposed to be derived from an 
embryo found in flsh. 

The embryo or ovum is introduced into the intestinal canal with 
the food and drink. The parasite reaches its final growth after its 
entrance into the intestines. 

Those handling fresh meats or eating uncooked animal food are 
most liable to be affected. 

Uncleanliness is also an important factor. 

Description. The t<znia solium is from six to thirty feet in 
length, has a globular head, or scolex, a slender neck connecting its 
numerous flat segments or Joints. The head, or scolex, measures 
about ■£$ of an inch, has a double circle of hooklets, — whence the 
term "armed tapeworm," — and is provided with from two to four 
suckers. The segments or joints (strobila) are flat, and vary from 
one-eighth to one-half of an inch in length, and each contains both 
male and female sexual organs, the uterus being a long, numerously 
branched tube, in which the ova develop ; the ova measures about 
tyVo of an inch in diameter. An ordinary tapeworm contains some 
five million ova. 

The parasite is firmly embedded in the mucous membrane of the 
upper third of the small intestines by its hooklets and suckers. 

The lower or terminal segments represent the adult and complete 
animal, and are termed the proglottides, which separate from the 
parasite and are discharged either alone or with the fasces. 

The tcenia saginata is from ten to forty feet in length, has a 
rounded or oval-shaped head, measures about ^ of an inch, and 
has four strong and prominent suckers, but no hooklets, — whence 
the term " unarmed tapeworm " ; the neck is short and thick and 
the segments are larger, stronger, and thicker than those of the taenia 
solium. 

The Bothriocephalus latus is the largest of the three Cestoda, the 
length ranging from fifteen to sixty feet, the head oval, measuring 
about y 1 ^ of an inch, a short neck, the segments or joints being nearly 
three times as broad as they are long. Its color is a dull, bluish-gray. 
Zoologically considered, this variety is not a true tapeworm. 



136 PRACTICE OF MEDICINE. 

Symptoms. Not unfrequently a tania produces no symptoms 
whatever. 

Usually, however, there are colicky pains throughout the abdomen, 
inordinate appetite, disorders of digestion, emaciation, constipation, 
attacks of cardiac palpitation, faintness, disorders of the special 
senses, and pruritus of the anus and nose. Any or all of these symp- 
toms may be present. 

A large meal will often remove the majority of the symptoms 
present. 

In a large number of cases the discovery of the segments is the first 
intimation of the presence of the parasite. 

Treatment. A number of remedies — termed tseniafuges — are 
used more or less successfully for the expulsion of the tapeworm. 

The very best of these remedies is undoubtedly oleoresincs aspidii, 
f£ss (2 Cc), repeated or in the following combination : 

R . Oleoresinse aspidii, f^ij 8. Cc. 

Chloroformi, f 3 ij 8. Cc. 

Olei tiglii, rr\Jv .24 Cc. 

Glycerini, f,lij 60. Cc. M. 

SlG. — Take half at 8 A. M. ; the rest in an hour if needed (Dock). 

The other tseniafuges often successful are : extractu??i granati rad. 
cort. fluidum, f^ss-ij (2-8 Cc), or a decoctum granati rad. cort. 
(^ij — 60 Gin. — bark of root, aquae Oj — 480 Cc), wineglassful every 
hour until all is taken, as suggested by Prof. Bartholow ; or oleum 
pepo express., f^j-iv (4-15 Cc), followed by oleum ricini. 
Creosotum has been successful in a number of cases. Several cures 
are reported from glycerinum, f3ij-f|jj (8-30 Cc), repeated p. r. n. 

A much pleasanter remedy is pelletierine, the active constituent of 
granafum, used in the form of the ta?inate, gr. x-xx (0.65-1.3 Gm.), 
or Tanrefs solution of pelletierine. 

An important precaution in the management is close attention to 
the " preparatory treatment " rendered essential to remove the mucus 
in which the head (scolex) is embedded. It consists in the adminis- 
tration of a thorough purgative for one or two days, and a light diet, 
such as milk and broths, preceding the use of the taeniafuge. 



INTESTINAL PARASITES. 137 

ROUND WORMS. 

Varieties. Ascaris lumbricoides ; Oxyuris vermicularis. 

Causes. The ascaris lumbricoides is one of the most common of 
the parasites affecting the human family, and develops in the intes- 
tines, either after the entrance of the ova of the same, or from the so- 
called " intermediate parasites." Their entrance is effected by means 
of the food and drink. 

The oxyuris vermicularis develops in the large intestines, from 
either its peculiar ova or the so-called " intermediate parasite," these 
finding their way into the bowel with the food and drink, or by direct 
contact. 

Description. The ascaris lumbricoides, or the round worm, is of a 
brownish color, a cylindrical body, from ten to twenty inches in length, 
and from an eighth to a fourth of an inch in circumferenct ; the head 
terminates in three semilunar lips, each having about two hundred 
teeth. The ova are oval-shaped, are produced in immense numbers, 
some sixty million in a mature female, have wonderful vitality, resist- 
ing extreme heat or cold. 

The round worm inhabits principally the small ifitestines, although 
it often migrates to other parts. They are found in numbers from one 
to several hundred. 

The oxyuris vermicularis, thread, or seat worm, resembles an ordi- 
nary piece of white thread, measuring from a sixth to a half inch in 
length, the head terminating in a mouth with three lips, the tail ter- 
minating as a sharp point. The ova are oval, produced in large 
numbers, each female containing about ten thousand, and are sur- 
rounded by a stout envelope, which increases their vitality. 

The seat worm, as its name indicates, inhabits the large intestines, 
especially the rectum, although they frequently migrate to the sexual 
organs. They vary in number, sometimes the parts frequented being 
entirely covered. 

Symptoms. The ascaris lumbricoides, or round wor?n, may be 
present in great numbers and yet produce no characteristic symptoms 
other \ha.n gastric and intestinal irritation, causing picking the nose, 
foul breath, colicky pains, nausea and vomiting, diarrhoea, and dis- 
turbed sleep, such as tossing from side to side of bed and grinding 
the teeth. Any or all of these symptoms may be present or absent ; 
a positive diagnosis is only possible upon the passage of the parasite. 



138 PRACTICE OF MEDICINE. 

The oxyuris vermicularis, or seat worm, produces intense itching 
about the anus, with a desire for stool, the passages often containing 
much mucus, the result of the irritation produced by their presence. 
Should they migrate to the sexual organs, intense itching of these 
parts results, which, unless speedily corrected, leads in children to 
masturbation. 

Treatment. The ascaris lumbricoides are readily removed by 
the following "worm powder " : 

R . Santonini, gr. j^.-)-\] .016-.065-.13 Gm. 

Hydrargyri chlor. mitis, . . . . gr. y$—\) .02-2-. 13 Gm. M. 

Ft. chart. 
SiG. — At bedtime, followed by a dose of oleum ricini before breakfast. 

For the oxyuris vermicularis the above santoninum powder, with 
the use of enemata of quassia, alumen, sodii chloridum, or 

R. Acidi carbolici, gr. v-x .3-. 6 Gm. 

Aquae, Oj 480. Cc. 

according to the age, the injection not to be retained ; or an enema of 
a weak solution of corrosive sublimate (1 to 10,000). Always precede 
any of the medicated enemata by a large injection of water to unload 
and clear the rectum. Washing the anus and external genitals with 
a solution of acidum carbolicum should also be employed. For the 
pruritus ani apply a little unguentum hydrargyri or extractwfi ha?n-. 
am e lis Jluidu7n. 



TRICHINOSIS. 

Synonyms. Trichiniasis ; Trichinae; Trichina spiralis ; "flesh- 
worm disease." 

Definition. A typhoid condition, the result of the entrance of a 
parasite — the Trichina spiralis — into the intestinal canal, and their 
subsequent migration into the muscular structure; characterized by 
severe gastro-intestinal irritation, severe muscular soreness, and a low 
typhoid condition. 

Cause. The Trichina spiralis are introduced into the human 
body by eating the infected hog's flesh, either raw or but partly cooked. 

Description. The parasite is found in two forms, to wit : intes- 
tinal trichina, which is sexually mature, and muscle trichina^ which is 
sexually immature. 



INTESTINAL PARASITES. 139 

The intestinal trichina is a small, hair-like worm, the male meas- 
uring -^ of an inch, and the female }& of an inch in length ; the head 
is smaller than the rest of the body ; the tail of the male has a bi-lobed 
prominence, between the divisions of which the anal opening is placed, 
and from which a single spiculum can be protruded ; the female has 
a blunt, rounded tail, the reproductive outlet being situated toward 
the anterior part of the body ; the ova are very small, containing 
embryos being produced viviparously at the rate of at least one 
hundred each week after the entrance of the female into the intestinal 
canal. 

The muscle trichina develops its sexual apparatus after it has 
entered the intestinal canal of the host. 

The viable embryos discharged from the female are in a state of 
motion, and at once migrate from the intestines to the muscular 
structure of the individual, and here set up inflammatory action, 
they becoming surrounded by a~ capsule or shell in which they are 
coiled. 

After a time, in the muscle, the trichina undergoes a further change ; 
lime salts being deposited in and about the capsule and in the para- 
site itself, when minute specks of lime are seen distributed throughout 
the muscular structure. 

The development of the parasite from the period of impregnation 
up to the time of sexual maturity is, under favorable conditions, less 
than three weeks. Within two days from the ingestion of the infecte 3 
pork occurs' the maturation of the muscle larvae; in six days mo 
the birth of embryos occur, and in about two weeks the migrati 
progeny have arrived at their habitat, the muscular structure. 

Symptoms. These depend upon the number of parasites in 
infected food. According to Dr. Sutton, of Indiana, a piece of p 
the size of a cubic inch contained eighty thousand trichinae. Tr 
are three stages described, to wit : the intesti?ial, the migration, 
the encapsulation. 

Intestinal sta^e, a gastro-intestinal inflammation, with nausea, • 
iting, and watery diarrhoea, the severity depending upon the nu 
of the parasites ingested. 

Migration stage, a typhoid-like fever, rapid, feeble pulse, pi 
sweats, intense thirst, dry tongue and lips, and red, swollen fact 
soreness and tenderness of the inuscular structure, increased 1 
muscular act. As a rule the mind is clear but decidedly apath 



1-10 PRACTICE OF MEDICINE. 

Encapsulation Stage. If the number of parasites ingested has 
been few, recovery may occur in this stage ; but if the number has 
been large, the gastro-enteritis, fever, and muscular phenomena are 
severe, the patient is in a critical condition, between twenty and fifty 
per cent, succumbing. 

Diagnosis. Unless the physician has some intimation of the 
cause, cases are readily mistaken for either ordinary ileo-colitis or 
typhoid fever. 

Prognosis. Depends upon the number of trichinae in the pork 
eaten. Mortality between twenty and fifty per cent. 

Treatment. The preventive treatment consists in eating no pork 
that has not been so prepared as to kill any trichinae that might exist. 
If the parasites have been recently taken, within the first four or five 
days, emetics and purgatives or the stomach washed out with intes- 
tinal irrigation to remove them from the stomach and intestinal canal 
are indicated. After thorough action from these, attempts may be 
made to destroy such of the parasites as have escaped the action of 
the emetic or purgative. For this purpose much is said in favor of 
glycerini) one part ; aquce, two parts ; so that one teaspoonful (4 Cc.) 
of glycerinum be administered every hour ; or a trial can be made of 
acidum carbolicum and iinctura iodi, as suggested by Prof. Bartholow. 
Quinines sulphas gave the best results in the cases seen by Dr. Sutton. 

After migration has begun, the powers of life should be sustained 
by nourishing food, stimulants, and tonics, as "there are no drugs 
which have any influence upon the embryos in their migration through 
the muscles." (Osier.) 



DISEASES OF THE PERITONEUM. 



PERITONITIS. 

Synonym. Inflammation of the peritoneum. 

Definition. A fibrinous inflammation of the peritoneum, either 
acute or chronic, characterized by fever, intense pain, tenderness, 
tympanites, vomiting, and prostration. It may be limited to a 



DISEASES OF THE PERITONEUM. 141 

part, local t or it may involve the entire membrane, general, peri- 
tonitis. 

Causes. Acute variety : Intense cold ; protracted irritation by- 
blisters ; blows upon the abdomen ; penetrating wounds of the abdo- 
men ; inflammation or perforation of the stomach, intestines, gall or 
urinary bladder, vermiform appendix, or the surrounding parts ; in- 
flammation of the pelvic viscera ; septicaemia or pyaemia ; erysipelas ; 
hernia. 

Many surgeons doubt that peritonitis is ever an idiopathic disease, 
but that rarely it does so occur is probable. 

Chronic variety : Tuberculosis ; nephritis ; scrofula ; cancer ; 
sclerosis of the liver. 

Pathological Anatomy. Acute form : hyperaemia of the serous 
membrane, the capillaries distended and occasional extravasations of 
blood from their rupture; the normal secretion is arrested, and the 
shiny membrane becomes dull and opaque, from an exudation of pure 
fibrin, which is adhesive, gluing the parts together ; if the inflam- 
matory action is now arrested, it is termed adhesive peritonitis ; if, 
however, the action progress, an effusion of serous fluid is poured out 
into the peritoneal cavity, the amount varying from a few ounces to 
several gallons ; this is termed exudative peritonitis. If recovery 
result, the fluid is absorbed with much of the solid exudation, the 
unabsorbed portions forming adhesions between the membrane and 
the different abdominal organs, often causing great deformity and 
irregularity in their relations. 

Local circumscribed peritonitis is the same as general except that 
adhesions develop around the site of attack so rapidly that the inflam- 
matory action is encapsulated. Why this occurs in some cases an 
not in others is not known. Pus develops if the absorption is nr.. 
prompt or if any cachexia be present. 

The chronic form follows the acute, or is associated with tuberci 
losis, scrofula, Bright's disease, or sclerosis of the liver. 

The membrane is irregularly thickened and opaque, with stror 
adhesions to one or more coils of the intestine, the liver, or spleei 
the quantity of fluid present is small, purulent, or sero-purulent 
character, and encysted by the agglutinated membrane. 

Symptoms. Acute form : the onset is sudden, with a chill, fevi , 
101-3 , pulse 100-140, wiry and tense, severe pain, cutting or bori 
in character, and tenderness, becoming so great that the slight- 



142 PRACTICE OF MEDICINE. 

touch aggravates it, the decubitus being on the back with flexed 
thighs; the abdomen is distended and rigid, from constipation, effu- 
sion, and meteorism ; the diaphragm is pushed up as far as the third 
or fourth rib in severe cases, causing compression of the lungs and 
displacement of the heart, liver, and spleen. There is impaired appe- 
tite, intense thirst, and nausea and vomiting are almost constant, as 
is hiccough. The patient passes through the various steps of the dis- 
ease rapidly, collapse soon occurring. It is a clinical fact that a sub- 
normal temperature is of frequent occurrence in acute peritonitis. 

Secondary form, from extension, begins with local and gradually 
increasing pain, the temperature increases, tense pulse, and vomiting. 
If from perforation, it is announced by severe pain and all the 
symptoms of shock. 

Purulent peritonitis, usually secondary (most commonly seen in 
those with chronic Bright's disease), is accompanied with hectic 
phenomena. 

These symptoms continue from six to eight days, when they begin 
to decline and a tedious convalescence ensues, or pain and tender- 
ness grow more marked, strength fails, surface cold, pulse rapid, and 
collapse, with hippocratic face, anxious expression, pinched features, 
sunken eyes, and drawn upper lip. 

Chronic form, usually of tubercular origin, though other causes are 
given, shows irregular chills, fever, and sweats, distended abdomen, 
coftstipation alternating with diarrhoea, diffused tenderness, with 
points of intenseness and hardness; colicky pains during digestion, 
rapid emaciation, and failure of strength. Usually the lower portions 
of the abdomen give a dull note on percussion, from the presence of 
fluid, or scattered points of dullness, showing the presence of encysted 
fluid. 

Diagnosis. The question of diagnosis in peritonitis is of great 
importance, as it is so frequently, if not always, associated with the 
diseases and accidents of the abdomen. 

Acute gastritis differs from peritonitis in having a history of cor- 
rosive poisoning, severe pain, limited to the stomach, with early and 
severe vomiting; while the latter has fever, diffused abdominal pain 
and tenderness, with decided distention. 

Acute ente?'itis has localized pain and tenderness with marked 
diarrhoea; constipation being the rule in peritonitis. 

Rheumatism of the abdominal muscles occurs with a rheumatic 



DISEASES OF THE PERITONEUM. 143 

history, is subacute, lacks the great abdominal distention and suffer- 
ing expression of peritonitis, and, while tenderness exists, it is not 
aggravated by deeper pressure. 

Biliary colic, or the passage of a gall-stone, has, as a prominent 
symptom, excruciating pain, localized over the common bile duct, 
which is of a paroxysmal character and followed by slight passing 
jaundice. In renal colic the acute pain follows the course of the 
ureters, with retracted testicle and altered urinary secretion. 

Prognosis. Always uncertain, but if symptoms progress slowly, 
quite favorable, as fatal cases usually end during the first week. 
Cases from perforation unfavorable. 

Chronic peritonitis being generally of tuberculous origin, the prog- 
nosis is unfavorable, although partial and complete recovery results in 
the cases following the acute form of the disease. 

Treatment. The peritoneal membrane being of such vast extent, 
its general inflammation is one of the most formidable diseases the 
physician meets. 

Acute form : Idiopathic and robust cases, locally, leeches or wet 
cups, followed by cold or hot applications, as most agreeable, or 
covering the abdomen with a blister ; adynamic cases, dry cups, fol- 
lowed by warm applications medicated with tinctura opii. 

The profession is divided between two plans of treatment for peri- 
tonitis, one side favoring opium and the other party as strongly urg- 
ing saline purgatives and laparoto?ny. 

Prof. Da Costa says opium and quinines sulphas are the remedies 
indicated at the onset of the disease, to wit: at once hypodermic of 
morphines sulphas, gr. %.-% (0.016-0.022 Gm.), maintaining the effect 
by hourly doses of either morphines sulphas or option, by the mouth. 
Prof. Clark ascertained the tolerance of opium in this disease by the 
tremendous amounts used in a case under his care ; the first day 
he gave 200 gr., the second day 472 gr., the third day 236 gr., fourth 
day 120 gr., fifth day 54 gr., sixth day 22 gr., and on the seventh day 
8 gr. Prof. Clark found that, as a rule, however, morphince sulphas, 
gr. Yd-]i (0.011-0.016 Gm.), every two hours, would maintain the 
effects of the drug. The opium should be guarded with sufficient 
doses of atropines sulphas. Quinines sulphas, gr. v (0.3 Gm.), every 
four hours until exudation, after which gr. ij (0.13 Gm.), four times 
a day, is of marked benefit. 

While the opium treatment places the patient as well as the bowels 



144 PRACTICE OF MEDICINE. 

"in splints" and relieves the pain, it is urged by the advocates of 
saline purgatives, however, that instead of locking up the bowels, the 
use of salines puts the bowels into active peristaltic action, whereby 
the peritoneal cavity is drained of the products of inflammation and 
the inflamed surfaces are relieved of all engorgement by a thorough 
depletion of the vessels in the intestinal walls, the pulse and temper- 
ature are improved, the pain is lessened as quickly as by opium, and 
the formation of adhesions and bands is prevented. 

Should the active symptoms continue under either plan of treat- 
ment, laparotomy is indicated, and indeed there is a growing opinion 
that cases of peritonitis should at once be handed over to the surgeon. 

The decline of the vital powers must be averted by regulated nutri- 
tion and free stim ulation . 

Locally, an ointment of belladonna and hydrargyrum is of value. 

During convalescence, perfect quiet, nourishing diet, moderate stim- 
ulation, scattered flying blisters, and the following: 

rjt . Potassii iodidi, gr. v-x -3~-6 Gm. 

Ferri pyrophos., gr. ij .13 Gm. 

Elix. simpl., f^ ss 2 - Cc. 

Aquae destillatse, ad f 3 ij ad 8. Cc. 

Every six hours. 

should constitute the treatment, with tonic doses of quinines sulphas. 

Peritonitis from perforation, absolute quiet, hypodermic injections 
of morphincB sulphas, ice locally, and stimulants per mouth, rectum, 
or hypodermically, and laparotomy. 

For puerperal and other varieties of peritonitis following disease of 
ovaries, tubes, uterus, and laparotomy, the reader is referred to works 
on gynecology and surgery. 

Chronic peritonitis ; locally tinctura iodi, and internally opium, for 
pain ; potassii iodidum as an absorbent, with nourishing diet, oleu?n 
morrhucz and stimulants , and rest in bed. 



ASCITES. 

Synonyms. Dropsy of the abdomen ; peritoneal dropsy ; hydro- 
peritoneum. 

Definition. A collection of serous fluid in the abdomen, or more 
correctly in the peritoneal cavity ; characterized by a distended abdo- 



DISEASES OF THE PERITONEUM. 145 

men, fluctuation, dullness on percussion, displacement of viscera, 
embarrassed respiration, plus the symptoms of its cause. 

Causes. Ascites may form part of a general dropsy, to wit : car- 
diac or nephritic. The most common factor in its production is a 
mechanical obstruction of the portal system from cirrhosis of the liver, 
pressure of tumors, diseases of the heart or lungs. 

Pathological Anatomy. The quantity of fluid in the perito- 
neal sac varies from a few ounces to many gallons. It is generally 
of a straw color, or at times greenish, and is transparent, having an 
alkaline reaction. When blood is present in any great quantity, it 
points to cancer as a cause. The peritoneum becomes cloudy, sod- 
den, and thickened, from long contact with the fluid. 

Symptoms. The onset is insidious, and considerable swelling of 
the abdomen occurs before the disease attracts attention. Constipa- 
tion, from pressure of the fluid on the sigmoid flexure. Scanty 
urine, from pressure on the renal vessels. Emba7rassed respiration 
and cardiac action, from displacement of the diaphragm upward. 
The umbilicus is forced outward. 

Physical signs : on palpation , a peculiar wave-like impulse is im- 
parted to the hand lying on the side of the abdomen, while gently 
tapping the opposite side. 

Percussion : patient erect, the fluid distends the lower abdominal 
region, with dullness over the site of the fluid and a tympanitic note 
above ; if the patient turns on his side, the fluid changes, and dullness 
over the fluid, tympanitic note over the intestines. 

Diagnosis. Ovarian tumors differ from ascites in the history, in 
that the enlargement is limited to the iliac fossa, instead of a uniform 
abdominal enlargement, not changing its position when the patient 
changes posture, and by the detection of a tumor by conjoined 
manipulation through vagina, or by rectal exploration. 

Pregnancy differs from ascites in the character of the enlargement, 
the history, absence of menses, increase of mammae, change in the 
neck of the uterus, absence of fluctuation, and the presence of the 
sounds of the fcetal heart. 

Distention of the bladder has been mistaken for ascites ; the points 
of distinction are, in the former, the history, presence of tenderness 
over the bladder, rounded outline of the percussion dullness, and the 
relief afforded by the catheter. 

Chronic peritonitis is differentiated by the history, pain, tenderness, 
13 



146 PRACTICE OF MEDICINE. 

more or less vomiting, thickened abdominal walls, and its generally 
being associated with tubercle or cancer. 

Chronic tympanites presents the enlarged abdomen, but lacks the 
history, the dullness, and the fluctuation, giving instead a tense abdo- 
men and a universal tympanitic note. 

Prognosis. Influenced by the causes producing it. Idiopathic 
ascites, which is most rare, terminates in health within a few weeks. 
If peritoneal, generally favorable. If from organic disease, most 
unfavorable, for while the dropsy may be removed, it as rapidly 
returns. 

Treatment. The first indication is to treat the cause of the ascites 
and the second to remove the fluid. 

Three modes of removing the fluid present themselves : first, by 
hydragogue cathartics ; second, diuretics and diaphoretics, and third, 
tapping. The first and second modes may be combined, as follows : 

R. Pulv. jalapse comp. , 5J _ ij 4.-8. Gm. 

In water, an hour before breakfast ; 

And— 

R. Potassii acetat. , gr. xxx 2. Gm. 

Spts. aetheris nitrosi, . . . . rr^xv 1. Cc. 

Infus. digitalis, . . . q. s. adf^ij ad 8. Cc. M. 
Every six hours. 

Or instead use the following: 

R. Hydrargyri chlor. mitis, . . . gr. iij .2 Gm. 

Ext. opii, g r - tV - 00 5 Gm. M. 

Ft. pil. 

SlG. — One every three or four hours. 

If these fail, as they certainly will after a time, the embarrassed 
respiration and cardiac action will call for tapping, which may be 
done with the trocar or the aspirator. The tapping does not remove 
the cause, and the fluid often rapidly accumulates again. Before 
tapping always examine the bladder, using the catheter if there be 
any doubt. 

As all modes of treatment weaken the patient, the diet should be 
highly nutritious, and the system supported with strychnmce sulphas. 



DISEASES OF THE BILIARY PASSAGES. 147 



DISEASES OF THE BILIARY PASSAGES. 



CATARRHAL JAUNDICE. 

Synonyms. Catarrh of the bile ducts ; icterus. 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the bile ducts and of the duodenum ; characterized by 
gastro-intestinal derangement, yellowness of the skin and sclera, 
itching of the skin, feverishness, and mental depression. 

Causes. Excesses in eating and drinking; a debauch ; malaria; 
climatic, as cool nights succeeding warm days. 

Pathological Anatomy. The mucous membrane of one or 
more of the bile ducts, or of the duodenum, becomes hypersemic, 
swollen, and thickened, from an effusion of serum into the submucous 
tissue ; the result of this condition is the closure of the biliary pas- 
sages, thereby impeding the outward flow of bile. The bile in the 
hepatic ducts being retained by the obstruction, the result is a stain- 
ing of the liver substance and an absorption of bile, and its appear- 
ance in the blood. 

Symptoms. Begins by epigastric distress, coated tongue, im- 
paired appetite, nausea, with perhaps vomiting, and looseness of the 
bowels and slight feverishness, the phenomena of a gastro-intestinal 
catarrh. In from three to five days the eyes beconie yellow and jaun- 
dice gradually appears over the whole body ; the feverishness disap- 
pears, the skin becomes harsh, dry, and itchy, the bowels constipated, 
the stools whitish or clay-colored, accompanied with much, flatus, and 
colicky pains ; the urine heavy and dark, loaded with urates and con- 
taining biliary elements. 

A few drops of the urine placed on a whitish surface, and a drop or 
two of nitric acid made to flow against it, will exhibit the following 
"play of colors" : a greenish tint, from the conversion of bilirubin 
into biliverdin, quickly followed by blue, violet, red, and yellow, or 
brow 7i. 

When the jaimdice is complete, the surface is cold, the heart's action 
slow, the mind torpid and greatly depressed, and pain or tenderness 
on pressure over the hepatic region. 



]48 PRACTICE OF MEDICINE. 

Duration. In from three to five days after the jaundice appears 
the symptoms subside, save the torpid bowels, depression, and discol- 
ored skin, which slowly disappear, often requiring a week or two. 

Diagnosis. There are two varieties of jaundice, and in arriving 
at a diagnosis this must be remembered. There is hepatoge?ious, 
obstructive or catarrhal jaundice, and hematogenous, non-obstructive 
or blood-change jaundice. 

The numerous diseases of which jaundice is a symptom will be 
differentiated when treating of them. 

Prognosis. Catarrhal jaundice always favorable; if the attacks 
are of frequent occurrence, however, they are apt to lead to organic 
hepatic changes. If jaundice shows tendency to linger, it is probably 
result of organic condition. 

Treatment. Rest in bed, with a carefully regulated diet, avoiding 
all starchy, fatty, or saccharine articles, milk being the most suitable, 
adding lime-water if the stomach be irritable. 

The jaundice being the result of an acute catarrh of the duodenum 
and the ductus choledochus communis, treatment is to be directed to 
this condition by such remedies as sodii phosphas, 3j (4 Gm.), well 
diluted, every four hours, or calomel and soda(R. Hydrargyri chloridi 
mitis, gr. % (0.016 Gm.) ; sodii bicarbonatis, gr. iij (0.2 Gm.) ; sacc. 
lac, gr. iij (0.2 Gm.) ; M. Sig. — Taken dry on tongue every two or 
three hours until one dozen are used, followed by Hunyadi Janos 
water), or the following : 

R. Sodii bicarb., giv 15. Gm. 

Tinct. nucis vom., f.^iv 1 5- Cc. 

Tinct. capsici, fgj 4. Cc. 

Tinct. rhei, f t ^ij 60. Cc' 

Inf. gent, comp., . . . q. s. ad f]§vj ad 180. Cc. 

Sig. — Dessertspoonful every four or five hours, in water. 

For the dry, itchy skin diaphoresis is indicated. The warm or hot 
bath night and morning is valuable, adding potassii carbonas, 3J (30 
Gm.)to each. A weak carbolic solution often relieves a troublesome 
itching, and potassii bromidi,gr. xxx (2G111.), overcomes the insomnia 
and restlessness of itching. 

If the urine continues scanty, diuretics should be used, a simple and 
efficacious one being potassii bitartras lemonade at very frequent 
intervals. Spirilus cetheris nitrosi, rr^x-xx (0.6-1.3 Cc), diluted, is 
always valuable for torpid kidneys. 



DISEASES OF THE BILIARY PASSAGES. 149 

If under the above plans of medication the constipation continues, 
a pill of aloes and podophyllum may be useful. 

A special plan, which is said to be effective, is with " enemata of 
cold water. By means of an irrigating apparatus the large intestine 
is well distended with water once a day for several days. The first 
enema has a temperature of 6o° F., and subsequent injections are a 
little warmer. The increased peristalsis of the bowels and the reflex 
contractions of the gall-bladder dislodges the mucus obstructing 
the gall ducts. When the bile flows into the intestine, digestion is 
resumed and the catarrhal inflammation subsides." Other remedies 
may be conjoined with the irrigation method. 

For convalescence : 

R . Strychninse sulph., gr. ss .03 Gm. 

Acid, nitrohydrochloric. dil., . . f^iv 15. Cc. 

Tinct. gentian, comp., f^iiss 75. Cc. 

SlG. — Teaspoonful after meals, well diluted. 



BILIARY CALCULI. 

Synonyms. Hepatic calculi ; gall-stones ; hepatic colic. 

Definition. Concretions originating in the gall-bladder, or biliary 
ducts, derived partly or entirely from the constituents of the bile. 
Their presence is generally unrecognized until one or more attempt 
to pass along the ducts, when an attack of hepatic colic is produced. 

Causes. Gall-stones result from the precipitation of the crystal- 
lizable ckolesterine, and its combination with inspissated mucus in the 
gall-bladder or ducts. 

A disease of middle life, and more frequent in the obese, and in 
women. 

Gall-stones are said to be common in carcinoma of the stomach or 
liver. 

Pathological Anatomy. Cholesterine is the chief constituent 
of biliary calculi. Commonly several stones exist, and rarely one ; 
as many as six hundred are recorded. They are generally found in 
the gall-bladder or cystic duct, rarely in the liver or hepatic duct. 

Symptoms. The presence of gall-stones or biliary calculi is 
made known only by their expulsion from the gall-bladder, whence 
is developed hepatic colic. 



150 PRACTICE OF MEDICINE. 

Hepatic colic begins suddenly, at the moment a gall-stone passes 
from the gall-bladder into the cystic duct. 

The patient is seized with a piercing, agonizing pain in the region 
of the gall-bladder, and spreading over the abdomen, right chest and 
shoulder; the abdominal muscles are cramped and tender ; there are 
nausea and vomiting, a small, feeble pulse, cool skin, pale, distorted, 
anxious face, with, may be, fainting, spasmodic trembling, chills, or 
convulsions. 

The paroxysm continues from an hour or two to several days, with 
remissions, but entire relief is not afforded until the stone reaches the 
duodenum, when the pain suddenly ceases. 

Jaundice usually follows the paroxysm of pain. When the calculi 
reaches the intestines, the pain, nausea, and vomiting cease, the appe- 
tite returns, and the jaundice soon disappears. 

Should the calculi become impacted, ulcerative perforation and 
consequent peritonitis follow, the calculi discharging by the intestine, 
stomach, or through the abdominal walls. 

Diagnosis. The malady should not be mistaken if severe pain, 
diverging from the hepatic region, and nausea and vomiting are 
present, suddenly terminating, and followed by slight jaundice. The 
diagnosis is always made positive by diluting the stools voided for the 
day following an attack of suspected hepatic colic, and passing them 
through a sieve, when the stone will be secured if present. 

Prognosis. Usual termination is in health. The prognosis be- 
coming more unfavorable if ulcerative perforation result. 

Treatment. For the colic, hypodermic injections of morphifice 
sulphas, gr. l /6- l /i-}i (o.oi 1-0.022-0.3 Gm.), combined with atropines 
sulphas, gr. -^ (0.001 Gm.), and warm fomentations over the hepatic 
region, are indicated. Oleum olives puree, fjij-iv (60-120 Cc), every 
hour or two, sometimes does good. 

Prof. Bartholow strongly urges the following prophylactic treat- 
ment : Carefully regulated diet, abstinence from all fatty and sac- 
charine substance, daily exercise, stoppage of all excesses, and the 
long use of sodii phosphas, Z) (4 Gm.), before meals, well diluted, 
to which may be added, if gastro-intestinal catarrh be present, sodii 
arsenias, gr. fo (0.003 Gm.), or aurii et sodii chloridum, gr. ■£$ (0.003 
Gm.), together with either Vichy or Saratoga Vichy water. 



DISEASES OF THE LIVER. 151 



DISEASES OF THE LIVER. 



CONGESTION OF THE LIVER. 

Synonyms. Torpid liver ; biliousness. 

Definition. An abnormal fullness of the vessels of the liver, 
with consequent enlargement of that organ ; it is termed active 
when arterial ; passive when venous. The condition is characterized 
by torpidity of the digestive and mental functions, and slight jaun- 
dice. 

Causes. Active congestion ; heat, atmospherical or artificial ; 
habitual constipation ; malaria ; excesses in eating and drinking ; 
alcoholic or malt liquors. In females, an arrested menstrual epoch 
may give rise to an attack. 

Passive congestion ; cardiac and pulmonary diseases. 

Pathological Anatomy. The liver is enlarged in all direc- 
tions, and is abnormally full of blood. Cases due to obstructive 
diseases of the heart or lungs present the so-called "nutmeg liver," 
to wit: "At the centre of each lobule the dilated radicle of the 
hepatic vein, enlarged and congested, may be discerned, while the 
neighboring parts of the lobule are pale," the radicles of the portal 
vein containing less blood. 

Long-continued congestion establishes atrophic degeneration of the 
organ ; the decrease in size is confounded with the condition of cir- 
rhosis, but the " atrophic liver " is smooth, while the " cirrhotic liver " 
is nodulated. 

Symptoms. Active congestion ; following cause, rapidly pro- 
duced malaise, aching of limbs, evening feverishness, headache, 
depression of spirits, yellowish io7igue, disgust for food, nausea, and, 
may be vomiting, constipation, scanty, high-colored urine, with a 
feeling of fullness, weight, and soreness in the hepatic region, with 
dull pain extending to the right shoulder, and slight jaundice, the eye 
yellow, and the complexion muddy. Duration about a week. 

Passive congestion; onset gradual, with a feeling of weight and 
fullness in the hepatic region, slight jaundice, and symptoms of gas- 
trointestinal catarrh. 



152 PRACTICE OF MEDICINE. 

On percussion the hepatic dullness is increased in all directions. 

Diagnosis. Acute congestion is continually confounded with 
catarrhal jaundice ; the latter begins with marked gastro-intestinal 
symptoms and distinct jaundice ; in the former these are less 
marked. 

Obstructive congestion is diagnosticated by the clinical history. 

Atrophic or nutmeg liver will be differentiated from cirrhotic liver 
when speaking of the latter. 

Prognosis. Active congestion favorable, unless repeated attacks 
occur, rapidly succeeding each other, when " atrophic degeneration " 
results. 

Passive co7igestion controlled entirely by the cause. 

Treatment. Attacks due to excess in eating and drinking — 

R . Sodii bicarb. , gr. v .3 Gm. 

Pulv. ipecac, gr. ss .03 Gm. 

Hydrargyri chloridi mit., . . . gr. iij-v - 2_ -3 Gm. 

repeated, followed by saline, or sodii phosphas, Z) v4 Gm.), every 
four hours until free catharsis, or followed by 

EL. Acid, nitro-hydrochloric. dil., . . rt^x .6 Cc. 

Elix. taraxaci comp., f^ij 8. Cc. 

Before meals. 

Attacks due to malaria ; the above purgatives, followed by quinines 
sulph., gr. iv (0.26 Gm.), every four hours. 

Attacks occurring with cardiac or pulmonary diseases must be 
managed by treating the cause. 

The tendency to constipation must be overcome by the saline laxa- 
tive waters, to wit : Congress or Hathorn, Hunyadi Janos, or sodii 
phosphas, 3j-ij (4-8 Gm.) three or four times daily, well diluted. 

Locally, in acute attacks, hot cloths or sinapisms are of benefit. 

In chro7iic cases benefit follows the long use of strychnines arseniai. 
or sodii arse?iiai., and great comfort and support is given by the use 
of the " hydropathic belt," which is made of stout muslin, shaped to 
the abdomen, with cross-pieces of tape on the inner side, which keeps 
next to the skin a fold of cloth wrung out of cold water, and a piece 
of waterproof cloth or oiled silk, to prevent evaporation. 

In persons who seem to have a predisposition to attacks of conges- 
tion of the liver upon the slightest exposure to any of the various 



DISEASES OF THE LIVER. 153 

exciting causes, the habits and diet must be regulated, adding a 
course of alkaline waters and regulated exercise. 



ABSCESS OF THE LIVER. 

Synonyms. Parenchymatous hepatitis ; acute hepatitis ; sup- 
purative hepatitis. 

Definition. A diffused or circumscribed inflammation of the 
hepatic cells, resulting in suppuration, the abscesses being sometimes 
single, at times double ; characterized by irregular febrile attacks, 
hepatic tenderness, and symptoms of deranged gastro-intestinal and 
hepatic functions. 

Causes. The result of the absorption of putrid material by the 
portal radicles in dysentery ; ulcers of the stomach ; malaria ; blows 
and injuries ; heat ; associated with or following pyasmic abscess. 

Pathological Anatomy. If the result of inflammation, usually 
have one large abscess ; if secondary to pyasmic conditions, have a 
number of small abscesses (multiple abscess). Usually found on 
right lobe. Hyperaemia, swelling, effusion of lymph, degeneration 
and softening of the hepatic cells ; suppuration, beginning in points 
in the lobules and coalescing. The abscess walls consist of the liver 
structure, more or less changed. 

The abscess may advance toward the surface of the liver, bursting 
into the peritoneum, intestines, stomach, gall-bladder, hepatic duct 
or vein, or into the pleura or lungs, or externally through the 
abdominal walls ; after the discharge of pus, cicatrization occurs, 
or the pus may be absorbed, the tissues around forming a dense 
cicatrix. 

Symptoms. Very obscure. Fever simulating markedly inter- 
mittent or remittent fevers ; disorders of the gastrointestinal canal 
with obstinate vomiting, debility, and great irritability of the nervous 
system, ?nelanc/iolia, slight Jaundice, constipation, the stools light col- 
ored, and if of long duration, typhoid symptoms. 

Locally, if the abscess is near the surface, prominence of the hepatic 
region, throbbing, limited tenderness, and if the abscess tends to the 
surface, redness, oedema, and fluctuation. The abscess may burst 
into the intestines, stomach, lungs, or pleura, the symptoms of which 
conditions will be pronounced. 
14 



154 PRACTICE OF MEDICINE. 

Diagnosis. Hepatic abscess may be confounded with hydatids 
of the liver, hepatic or gastric cancer, abscess of the abdominal walls, 
and purulent effusion in the right pleural cavity. 

The differentiation is most difficult, but grea t aid is obtained from 
the use of the aspirator. 

Prognosis. Unfavorable. Recoveries, however, do occur. If 
the abscess bursts into the lungs, bowels, or externally through the 
abdominal wall, the case is more favorable. 

Treatment. Symptomatic \ and when pus is present, the use of 
the aspirator to remove it, and sustaining treatment, quinince sulphas, 
ferrum, alcohol, and oleum 7norrhuce. 



ACUTE YELLOW ATROPHY. 

Synonyms. General parenchymatous hepatitis ; malignant jaun- 
dice ; hemorrhagic icterus. 

Definition. An acute, diffused, or general inflammation of the 
hepatic cells, resulting in their complete disintegration ; characterized 
by diminution in the size of the liver, deep jaundice, and profound 
disturbance of the nervous system ; terminating in death, usually, 
within one week. 

Causes. Unsettled. It occurs frequently (?) in young pregnant 
women, from the third to the sixth month of pregnancy. Other 
causes are venereal excesses, syphilis, action of phosphorus, arsenic, 
or antimony. 

Pathological Anatomy. Begins with hyperaemia of the 
hepatic cells, with a grayish exudation between the lobules, followed 
by softening, dull yellow color, and disappearance of the cells, fat 
globules taking their place ; the liver is reduced in size and weight ; 
the peritoneum covering the liver is thrown into folds ; the spleen is 
enlarged; the kidneys undergo degeneration; the blood contains a 
large amount of urea and considerable leucin ; the urine is loaded 
with bile pigment, and contains albumin. 

Symptoms. Prodromic period : begins as a gastro-intestinal 
catarrh, coated tongue, nausea, vomiting, tenderness over the epigas- 
trium, headache, quickened pulse, slight fever and slight jaundice. 

Icteric period : jaundice deepens, pulse slow, headache increases, 
and persistent insomnia. 



DISEASES OF THE LIVER. 155 

Toxcemic period : fever ; rapid pulse, more complete jaundice, pain, 
nausea, vomiting of blackish grumous blood, or "coffee grounds," 
tarry stools, ecchymotic patches, convulsions or epileptiform attacks, 
coma, insensibility, death. 

Percussion shows markedly decreased hepatic dullness. 

Duration. Short. After appearance of jaundice, about six days. 

Prognosis. Unfavorable. 

Treatment. Entirely symptomatic. Prof. Bartholow "advises 
the trial of very small doses of phosphorus, as early as possible, as 
this remedy affects the organ specifically, and an action of antagon- 
ism may be discovered between them." 



SCLEROSIS OF THE LIVER. 

Synonyms. Interstitial hepatitis ; cirrhosis of the liver ; hob- 
nailed liver ; gin-drinkers' liver. 

Definition. An inflammation of the intervening connective 
tissue of the liver, chronic in its progress, resulting in an induration 
or hardening of the organ, and an atrophy of the secreting cells ; 
characterized by gastro-intestinal catarrh, emaciation, slight jaundice, 
and ascites. 

Causes. The prolonged use of alcoholic stimulants, gin, whisky, 
beer, or porter ; syphilis. I have seen two cases in persons suffering 
with uric acid diathesis who were not alcoholics. 

Pathological Anatomy. First stage : hypersemia of the con- 
nective tissue (Glisson's capsule) of the liver, and the development 
of brownish-red connective-tissue elements, whereby the organ is 
increased in size and density ; this increase of the connective tissue 
presses upon the hepatic cells, causing them to undergo fatty degen- 
eration. 

Second stage : the newly formed, imperfectly developed connective 
tissue contracts, causing decrease in the size and induration of the 
organ, its surface being nodulated. The hepatic and portal circula- 
tion is obstructed, from obliteration of their radicles. 

The hepatic peritoneum is thickened and opaque, and adhesions 
are formed to the diaphragm, gall-bladder, and stomach. 

The changes in the hepatic structure interfere with the venous cir- 
culation of all the abdominal organs, with the consequent venous con- 



156 PRACTICE OF MEDICINE. 

gestion of the stomach, spleen, pancreas, intestines, and peritoneum, 
and enlargement of the abdominal veins. 

Cases occur in which the sclerosis takes place while the organ 
continues enlarged ; these cases are known as hypertrophic sclerosis. 
But whether the liver be diminished or increased in size, both are 
the result of an abnormal development of connective tissue, in one 
case contraction being a prominent feature, and in the other not 
so. 

Symptoms. No characteristic symptoms of the early stage of 
the affection. Persistent gastro-intestinal catarrh, with attacks of 
jaundice, in a drinking man, are suspicious. Symptoms of the second 
stages are abdominal dropsy, enlargement of the superficial abdominal 
veins, dyspepsia, localized peritoneal pain, hemorrhages from the 
stomach ox intestines, muddy or slightly jaundiced skin and decided 
emaciation; the enormously distended abdomen with thin legs are 
characteristic of sclerosis of the liver. 

I have seen two cases in which the condition was unsuspected 
until the development of a gradually increasing and persistent epis- 
taxis, which continued until death, within a month of the onset, the 
liver being far advanced in sclerosis without any rational symptoms. 

Diagnosis. Atrophy of the liver, or the nutmeg liver, is almost 
always confounded with sclerosis ; the former occurs most commonly 
with obstructive diseases of the heart and lungs, and the surface of 
the organ is not nodulated, nor is there a history of alcoholism. 

Cancer and tubercle of the peritoneum have many symptoms akin 
to sclerosis. The points of differentiation are, great tenderness over 
abdomen, rapidly developed ascites, rapid decline in strength and 
flesh, absence of jaundice, absence of long-continued dyspepsia, ab- 
sence of hepatic changes on percussion, and the presence of tubercle 
or cancer deposits in other organs. 

Prognosis. Terminates in death. Average duration after ap- 
pearance of the dropsy, one year. 

Treatment. For the changes in the hepatic structures, little, if 
anything, can be done; the following are some of the remedies rec- 
ommended, to wit : hydrargyri chloridum corrosivum, gr. fa—fa (o.ooi- 
o 002 Gm.), three times a day ; hydrargyri chloridum mite, gr. T £y 
(0.00065 Gm.), three times a day ; aurii et sodii chloridum, gr. fa 
(o 003 Gm.), after meals ; sodii phosphas, 3ss-j (2-4 Gm.), after 
meals ; potassii iodidum, after meals. 



DISEASES OF THE LIVER. 157 

The diet must be regulated, milk being the most suitable, and 
particularly avoiding fatty and saccharine foods. 

The abdominal dropsy maybe temporarily benefited by purgatives 
and diuretics, but sooner or later tapping becomes necessary. 



AMYLOID LIVER. 

Synonyms. Waxy liver; lardaceous liver; scrofulous liver; 
albuminous liver. 

Definition. A peculiar infiltration into, or a degeneration of, the 
structure of the liver, from the deposit of an albuminoid material 
which has been termed amyloid, from a superficial resemblance to 
starch granules. 

Causes. The chief cause is prolonged suppuration, especially of 
the bones ; coxalgia ; syphilis ; cancer. 

Pathological Anatomy. The liver is uniformly enlarged. It 
presents a pale, glistening, translucent appearance, and has a doughy 
consistency. On section, the surface is homogeneous, is anaemic and 
whitish. The deposit begins in the arterioles and capillaries, finally 
closing them. 

The reaction with iodine and sulphuric acid affords a certain test 
of the amyloid or albuminoid deposits. After further cleansing, brush 
over the parts a solution of iodine with iodide of potassium in water, 
when they will assume a mahogany color, and if diluted sulphuric 
acid be added, a violet or bluish tint is produced. 

A pretty reaction is to take a one per cent, solution of aniline violet, 
which strikes a red or pink color with the amyloid or albuminoid 
material, while the unaltered tissues are stained blue, thus showing a 
beautiful contrast. 

The amyloid change involves the spleen, kidney, intestines, and 
other organs. 

Symptoms. Nothing characteristic. Hepatic dullness increased, 
with prominence over the liver ; absence of pain ; splenic dullness 
increased ; emaciation and anaemia ; urine increased in amount, pale 
and containing some albumin, due to amyloid changes in the kidneys. 
Disorders of digestion, with diarrhoea, due to amyloid changes in the 
intestines. Jaundice is rare. Ascites seldom occurs. 



158 PRACTICE OF MEDICINE. 

Prognosis. Unfavorable. The progress is rapid or slow, depend- 
ing upon the cause. 

Treatment. No specific. Prof. Da Costa recommends a?nmonii 
chloridum,gr. x-xx (0.6-1.3 Gm.), three times daily, for several weeks, 
then change for the same length of time to syrupus ferri iodidum, 
beginning with rr\,x (0.6 Cc), gradually increased to f£j (4 Cc.) after 
meals, then to the former again, and so on, for months. Life may 
be prolonged by the use of ferrum, syrupus calcii lactophosphas, 
and oleum morrhuce. 



HEPATIC CANCER. 

Synonym. Carcinoma of the liver. 

Definition. A peculiar morbid growth, progressively destroying 
the hepatic tissue; characterized by disorders of digestion, anaemia, 
emaciation, jaundice, and ascites, and terminating in the death of the 
patient. 

Causes. Hereditary, when it is termed primary cancer ; exten- 
sion from other organs, termed secondary cancer. It is a disease of 
advanced life, from forty to sixty years of age. 

Pathological Anatomy. The most common variety of cancer 
of the liver is a compound of the medullary and scirrhus. 

The cancer cells develop from the interlobular connective tissue, 
and as they grow the hepatic cells atrophy, the result of the pressure 
of the new growth. The branches of the hepatic artery enlarge 
and permeate the growth, while the branches of the portal vein 
are compressed and atrophied, thereby blocking up the portal circu- 
lation. 

The cancer may develop in nodules or masses, or maybe diffused ; 
the nodules vary in size, and those on the surface are rounded, with 
a central umbilication. The peritoneum is adherent, cloudy, and 
thickened. 

Symptoms. The development of hepatic cancer is preceded 
by a history of dyspepsia, flatulency, and constipation. Uneasiness, 
weight, and pain, increased by pressure, are noticed ; jaundice, 
ascites, occasionally intestinal hemorrhages, emaciation, feebleness, 
antzmia, cold, dry, harsh shift, pinched features, with dejected, worn 
expression. Fever never occurs unless there is some complicating 



DISEASES OF THE KIDNEYS. 159 

condition. The hepatic dullness is increased, with pains on palpa- 
tion, and the liver is indurated, irregular, and nodulated. 

The duration is less than a year from the time the disease is recog- 
nized. 

Diagnosis. The points of differentiation are the age, cachexia, 
pain, and tenderness, eti/arged liver with hard nodules, and rapid 
emaciation and progress of the disease. 

Prognosis. Always terminates in death. 

Treatment. Early symptomatic. Sooner or later opium must be 
used to relieve the terrible and persistent pain. 



DISEASES OF THE KIDNEYS. 



THE URINE. 

The normal quantity of urine voided varies from forty to fifty 
ounces (i 200-1 500 Cc.) in the twenty-four hours ; it is decreased by 
free perspiration and increased 'by chilling of the skin. 

Within the twenty-four hours, the least urine is passed during the 
night or in the early morning, very much the greater portion being 
passed during the course of the day. 

The normal color is light amber, due to urobilin ; the color deepens 
if the quantity voided be decreased, and vice versa. In nearly all 
normal urine a cloud of mucus forms after standing a short time. 

The normal reactio7i is slightly acid, due to the acid sodic phos- 
phate, uric and hippuric acids. After meals it may be neutral or 
even alkaline. 

The normal specific gravity varies from 1.015 to 1.02; it is low 
when an increased quantity is passed, and high when the quantity is 
diminished. 

The normal odor of urine is a peculiar, well-known, aromatic one ; 
it is altered by certain foods, such as the violet stench after eating 
asparagus, and the garlicky odor after using garlic. 



160 



PRACTICE OF MEDICINE. 



The most important organic and inorganic solid constituents held 
in solution, are urea (the index of nitrogenous excretion), from 308 
to 617 gr. daily ; uric acid, from 6 to 12 gr. ; urates of sodium, ammo- 
nium, potassium, calcium, and magnesium, from 9 to 14 gr. ; phos- 
phates of sodium, etc., from 12 to 45 gr., and chlorides of sodium, 
etc., from 154 to 237 gr. daily. 



I. Quantitative test 
for urea by hypobro- 
mite of sodium 
(Davy's method). 



II. Tests for urates 
and uric acid by nitric 
acid. 



Fill a graduated glass tube one-third full 
of mercury, and add one-half drachm of the 
24 hours' urine ; then fill the tube evenly 
full with a saturated solution of hypobroinite 
of sodium, and close it immediately with the 
thumb; invert the tube and place its open 
end beneath a sat. sol. of chloride of sodium ; 
the mercury flows out and is replaced by the 
solution of salt ; nitrogen gas is disengaged 
from the urea in the upper part of the tube. 

Each cubic inch of gas represents 0.645 Z x - 
of urea in the half-drachm, from which the 
amount passed in 24 hours may be calculated. 

Urine containing an excess of urates and 
uric acid, on cooling precipitates them (viz. : 
" brickdust deposits " in " pot de chambre "). 
Heat dissolves them to a certain extent. 

Nitric acid deprives the soluble neutral 
urates of their bases, and produces, at first, 
a faint, milky precipitate of amorphous acid 
urates ; adding more acid, the still less solu- 
ble red crystals of uric acid, resembling cay- 
enne pepper, are deposited. 

Put a small quantity of nitric acid in a 
test-tube, and pour the urine carefully down 
the sides of the tube upon it, and a zone of 
yellowish-red uric acid and altered coloring 
matter will form at their union ; and a dense, 
milky zone of acid urates above this, which, 
however, dissolve upon agitation. (See al- 
bumin test.) 



DISEASES OF THE KIDNEYS. 



161 



III. Quantitative test 
for uric acid by nitric < 
acid. 



IV. Test for the 
earthy and alkaline 
phosphates by the 
magnesium fluid. 



V. Test for the chlo- 
rides by nitrate of sil- 
ver. 



VI. Test for mucus 
by acetic acid and liq- 
uor iodi comp. 



To three ounces of the 24 hours" urine 
(after being slightly acidulated, boiled, and 
filtered while hot) add one-tenth as much 
nitric acid ; place in a cool place for 24 
hours, then collect the deposit of uric acid on 
a weighed filter, wash it thoroughly, and dry 
at 212 F. The increased weight represents 
the uric acid in part excreted, approximately. 

Heat or liquor potasses increases the cloud- 
iness caused by earthy calcium and magne- 
sium phosphates. Acetic or nitric acid clears 
it by dissolving them. 

To two ounces of urine add one-third as 
much of the following solution : R. Magnesii 
sulph., ammonii chloridi puri, liquor ammo- 
niae, each one part ; aquae destil., eight parts ; 
if the precipitate has a milky, cloudy appear- 
ance, the quantity of phosphates is normal ; 
if creamy, the phosphates are in excess. 

To a convenient quantity of urine add a 
small quantity of nitric acid, to prevent the 
formation of the phosphates and other salts 
of silver ; filter this, if cloudy ; add to this 
one drop of a solution of nitrate of silver (1 
part to 8) and the precipitate of white cheesy 
lumps of chlorides of silver denotes that the 
amount of chlorides is normal ; if, however, 
only a faint milkiness occurs, the chlorides 
are diminished. 

Mucus alone is not visible, but causes 
cloudiness, from having entangled mucous 
or pus corpuscles, epithelium, granules of so- 
dium urate, crystals of oxalate of lime, and 
uric acid in various amounts. 

Add to the urine a little acetic acid, or, in 
addition, a few drops of liquor iodi comp., 
when threads and bands of mucin are made 
visible. The addition of nitric acid dissolves 
them. 



162 



PRACTICE OF MEDICINE. 



VII. Test for albu- 
min by heat and nitric 
acid. 



Slightly acidulate the urine, if necessary, 
by addition of nitric or acetic acid, and boil; 
this causes a white deposit of coagulated 
albumin, which is not dissolved by nitric 
acid, unless the acid is in excess. 

Nitric acid causes a white deposit of 
coagulated albumin, which is dissolved if a 
large excess of acid be added. A delicate 
test is to put the nitric acid in the tube first, 
and then gradually pour the urine down the 
side of the tube upon it, when a while zone 
or ring of coagulated albumin appears. Pre- 
caution, see tests Nos. 3, 4, 11, and 13. 



VIII. Test for albu- 
min by picric acid 
(saturated, watery so- 
lution). 



Pour a quantity of urine into a test-tube, 
and add the picric acid solution drop by drop 
and, as it passes through the urine, it is fol- 
lowed by an opaque white cloud if albumin 
be present. The test is very striking and 
beautiful. If cloudiness appears some time 
after, instead of at the time, it shows noth- 
ing. The test will not detect as small an 
amount of albumin as heat or nitric acid. 



IX. Nitric - magne- 
sian test for albumin. 
The fluid is prepared 
by mixing 1 part of 
pure nitric acid with 5 < 
parts of a saturated 
solution of the sul- 
phate of magnesium, 
and filtering. 



X. Quantitative test 
for albumin. Approxi- ■< 
mately. 



One drachm of the reagent is poured into 
a perfectly clean test-tube ; the urine should 
be allowed to trickle slowly down upon the 
fluid ; if albumin be present in an amount 
as small as one one-hundredth of one per 
cent., this test will show a compact, dense, 
white layer. This is one of the best and 
most reliable tests for albumin. 

Add a few drops of nitric acid to a pro- 
portion of the urine, and boil ; set this away 
for 24 hours, and the proportionate depth of 
the resulting deposit is the comparative in- 
dication — viz. : M-Vl, etc. 



DISEASES OF THE KIDNEYS. 



163 



For minute traces of albumin Millard's fluid may be used ; it is a 
delicate test and requires care. The fluid consists of glacial carbolic 
acid (ninety-five per cent.), gij (8 Cc.) ; pure acetic acid, £vij (28 Cc); 
liquor potassae, gij, 3vj (84 Cc). 



XI. Test for 
by heat and 
acid. 



blood 
nitric 



XII. Test for blood 
by heat and caustic \ 
potash (Heller's). 



XIII. Test for pus 
by liquor potassae. 



XIV. - Test for bile 
by "fuming" or red " 
nitric acid. 



Heat or nitric acid causes deposit of albu- 
min, with the coloring matter changed to a 
dirty brown. 

Heat the urine, then add caustic potash 
and heat anew. The phosphates are thus 
precipitated, taking with them the coloring 
matter of the blood, which imparts a dirty, 
yellowish-red color to the sediment, viewed 
by reflected light, and when seen by trans- 
mitted light, gives a splendid blood-red 
color. 

Neither the coloring matter of the blood, 
nor that of the bile, is precipitated with the 
phosphates, so that coloration of urine which 
shows this reaction cannot be ascribed to 
the presence of the latter pigments. 

When the quantity of blood in the urine 
is very large, it is of a dark or brownish-red, 
and, after standing, forms a coagulum of 
blood at the bottom of the vessel. 

Caution. Heat or nitric acid causes co- 
agulation of the albumin. 

Add to the urine, or preferably to its de- 
posit from standing, an equal volume of 
\ liquor potassce ; when well mixed, a viscid 
gelatinous fluid or mass is formed, which 
I pours like the white of an egg, or jelly. 

Allow a specimen of urine and a few drops 
of red " fuming " nitric acid to gradually 
intermingle on a porcelain dish, and a " play 
of colors," green, blue, violet, red, a.ndyello7v 
or brown occurs, if biliary coloring matter be 
present. 



164 



PRACTICE OF MEDICINE. 



XV. Test for bile 
pigmejit by pure hy- 
drochloric and pure 
nitric acids (Heller's). 



Pour into a test-tube about i.6-f£ of pure 
hydrochloric acid, and add to it, drop by 
drop, just sufficient urine to distinctly color 
it. The two are mixed. Then drop down 
the side of the test-tube pure nitric acid, 
which will " underlay " the mixture of hydro- 
chloric acid and urine. At the point of 
contact between the mixture and the color- 
less nitric acid a handsome "play of colors" 
appears. If the "underlying" nitric acid 
is now stirred with a glass rod, the set of 
colors which were superimposed upon one 
another will appear alongside of each other 
in the entire mixture, and should be studied 
by transmitted light. 

If the hydrochloric acid, on addition of 
the biliary urine, is colored reddish-yellow, 
the coloring matter is bilirubin; if it is col- 
ored green, it is biliverdin. 



XVI. Test for sugar 
by liquor potassae and < 
heat (Moore's). 



Add to the urine half its volume of liquor 
potasses. ( Caution. This may give a white, 
flaky precipitate of the earthy phosphates, 
which should be removed by filtering.) Now 
boil ; this causes, at first, a yellow-brow7iish 
color, becoming darker if much sugar is 
present, due to glucic and finally to melassic 
acid. 



XVII. Test for 
sugar by subnitrate of 
bismuth, liquor potas- 
sae and heat. 



Add to the urine half its volume of liquor 
potasses, and then a little bismuth subnitrate, 
shake, and thoroughly boil ; the presence of 
sugar reduces the salt and black metallic 
bismuth is deposited, or, if but little sugar, a 
gray deposit occurs. 

Caution. Albumin must be absent. 



DISEASES OF THE KIDNEYS. 



165 



XVIII. Test for 
sugar by a solution of 
cupric sulphate, liquor < 
potassae, and heat 
(Trommer's). 



Add to the urine a few drops of a solution 
of cupric sulphate, and then its own volume 
of liquor potasses. (Caution. On first addi- 
tion a light greenish precipitate occurs, 
which, on further addition of the reagent, if 
sugar or certain other organic matters are 
dissolved, giving a transparent blue liquid.) 
Now boil, and a yellowish precipitate of 
hydrated cupric suboxide, occurring at once, 
denotes the presence of sugar. 

Caution. Albumin must be absent. 



XIX. Quantitative 
test for sugar by Pavy's 
solution, to wit : 

R 

Cupric sulphate, 320 gr. 
Neutral potassic 

tartrate, . . 640 gr. 
Caustic potash, 1280 gr. 
Distilled water, 2of^. 

Keep corked. 



Take of Pavys solution of cupric protox- 
ide, recently prepared (see margin), 200 
minims or a multiple of this quantity, and 
boil in a porcelain dish ; while boiling, add 
minim by minim, from a measured portion 
of the 24 hours' urine, and it gives a yellow- 
ish precipitate of hydrated cupric suboxide, 
if sugar be present. 

Note carefully the gradual disappearance 
of the blue color, and when coinpieted (best 
determined by looking through the margin 
of the fluid against the white porcelain dish), 
from the amount of urine used determine 
the amount of sugar passed daily. The 
quantity of urine containing one grain of 
sugar being just sufficient to reduce the 200 
minims of the copper solution. 



XX. Quantitative 
test for sugar by fer- 
mentation and the 
specific gravity. 



Take two measured specimens from the 
24 hours' urine, and to o?ie add a little yeast. 
Place each specimen in a temperature of 75 
to 8o° F. ; in 24 hours fermentation hav- 
ing destroyed the sugar in the one contain- 
ing the yeast, the difference in the specif c 
gravity of the two specimens expresses the 
number of grains in each ounce of the urine, 
approximately. 



166 



PRACTICE OF MEDICINE. 



XXI. Tests for In- 
doxyl-potassium sul- „ 
phate (Indican ?). 

Note. — If the urine con- 
tain albumin, it must be 
removed before applying 
these tests, otherwise the 
blue color often arising 
from the mixture of hydro- 
chloric acid and albumin 
after standing may prove 
misleading.— Purdy. 



XXII. Ehrlich's 
diazo-reaction test. 



I. McMunris Method: Equal parts of 
urine and hydrochloric acid, with a few drops 
of nitric acid, are boiled together, cooled, and 
agitated with chloroform. The fluid is col- 
ored violet, and shows an absorption band, 
before D, due to indigo blue, and another 
after D, due to indigo red. 

II. Taffes Method : Mix 10 Cc. of strong 
hydrochloric acid with an equal volume of 
urine in test-tube, and while shaking add, 
drop by drop, a perfectly fresh saturated 
solution of chloride of lime, or chlorine- 
water, until the deepest attainable blue color 
is reached. The mixture should next be 
agitated with chloroform, which readily takes 
up the indigo and holds it in solution. The 
quantity is estimated by depth of blue color. 

III. Pour 4 Cc. of hydrochloric acid into a 
small flask, and while stirring add from 10 
to 20 drops of urine. If the proportion of 
indigo be above normal, the resulting color 
will be rather light yellow ; if in excess, the 
acid will turn violet or blue, — the more in- 
tense will be the color in proportion to the 
quantity present. If no coloration appears 
after waiting a minute or two, there is no 
excess, no difference how deep a color may 
subsequently appear. 

I. Take 2 Gm. (30 gr.) of sulphanilic acid, 
50 Cc. of hydrochloric acid, and 1000 Cc. of 
distilled water. 

II. Take solution sodium nitrite in water 
of the strength of 0.5 per cent. Place fifty 
parts of No. I and one part No. II in a test- 
tube and add equal amount of urine. The 
entire contents is rendered strongly alkaline 
by strong ammonia water. 

If the diazo-reaction occur, the mixture 
becomes ca7'tnine red ; now shake the tube, 
and if the red color is seen in the foam, the 
test is complete. Allow the tube to stand a 
day and a green precipitate forms. 



DISEASES OF THE KIDNEYS. 167 



CONGESTION OF THE KIDNEYS. 

Synonyms. Renal hyperemia ; catarrhal nephritis. 

Definition. An increase in the amount of blood in the vessels 
of the kidneys ; when arterial, it is termed active congestion ; when 
venous, passive congestion ; characterized by pain, frequent desire for 
urination, the amount of urine scanty, high-colored, occasionally 
containing albumin or blood. 

Causes. Active: from cold; irritating substances eliminated by 
the kidneys, as turpentine, copaiba, cantharides, carbolic acid, nitrate 
or chlorate of potash ; during the eruptive or continued fevers ; in- 
juries over the kidneys. 

Passive : obstructive diseases of the heart or lungs, pressure of the 
pregnant uterus. 

Pathological Anatomy. The kidneys enlarge and increase 
in weight ; increased redness (the color being bluish if passive), with 
points of vascularity, corresponding to the Malpighian bodies, and 
occasionally minute ecchymoses. The abnormal hyperemia causes 
a catarrhal state of the ducts of the pyramids, with shedding of their 
epithelium. 

If mechanical {passive) obstruction continues for some time, in- 
crease of the connective tissue with consequent induration and con- 
traction results, or a form of chronic Bright's disease. 

Symptoms. Active variety : pain over kidneys and following 
the course of the ureters into the testicles and penis, irritable bladder, 
almost constant and pressing desire for urination, the urine scanty, 
high-colored, and occasionally bloody, with fibrin, casts, and albumin ; 
there is, as a rule, no pain during the act of urination. The constitu- 
tional symptoms are headache, slight nausea, vomiting, and a general 
feeling of discomfort. 

If the condition persist, inflammation of the kidney results. 

Passive : the kidney changes are masked by the lung or heart 
trouble, until dropsy, scanty high-colored albwninous urine is ob- 
served. 

Prognosis. Active ; if recognized and properly treated, favorable. 

Passive : controlled by the cause, and if prolonged, terminating in 
interstitial nephritis. 

Treatment. The most important indication is to ascertain and 



168 PRACTICE OF MEDICINE. 

remove the cause. Rest of the body ; dry or wet cups over the loins ; 
dilute the urine by increasing the quantity of bland fluids consumed; 
saline purgatives ; warm bath or other mild diaphoretics. Infusu?n 
digitalis is pre-eminently the remedy for congestion of the kidneys ; 
if great irritability of the bladder, camphora, gr. ij-iv (0.13-0.26 
Gm.) every four hours, combined with morphine? sulphas, gr. -y%-\ 
(0.005-0.01 1 Gm.), or the hypodermic injection of 7norphin<2 sul- 
phas, gr. -^2 (0005 Gm.). 

The treatment of the passive form resolves itself into the treatment 
of the cause, remembering that there is too much blood in the veins 
and too little in the arteries. There are three ways of restoring the 
circulation. By venesection, opening a large vein ; by increasing the 
power of the heart by the use of digitalis or strophanthus, preferably 
the first named ; and by dilatation of the capillaries with inhalations 
of ainy I nitrite or the internal use of spiritus glonoini (nitro-glycerin 
1 per cent, solution), H\j-iij (0.06-0.18 Cc.) every four hours. The 
bowels should be kept soluble by salines. 



ACUTE PARENCHYMATOUS NEPHRITIS. 

Synonyms. Acute Bright's disease ; acute desquamative ne- 
phritis ; acute tubal nephritis ; acute croupous nephritis. 

Definition. An acute inflammation of the epithelium of the 
uriniferous tubules ; characterized by fever, scanty, high-colored, or 
smoky urine, dropsy, with more or less constant nervous phenomena, 
the result of acute uraemia. 

Causes. The young more liable than the aged ; cold and ex- 
posure ; scarlatina, diphtheria, and other infectious diseases; per- 
sistent use of irritants, as turpentine, cantharides, phosphorus, ginger, 
and others. Blows and injuries of the back have caused acute 
nephritis. Pregnancy is not an uncommon cause, resulting frequently 
in puerperal convulsions. Malarial poisoning. 

Pathological Anatomy. The kidneys are generally swollen, 
engorged, more vascular, and of red color; in the second stage the 
organ remains large, irregularly red, especially the cortex ; the 
tubules are engorged and filled with epithelium, blood corpuscles, 
and fibrin. The capsule is easily detached, and is more opaque than 
normal. 



DISEASES OF THE KIDNEYS. 169 

If a favorable termination, the swelling lessens, the vascularity 
diminishes, the tubules returning to their normal condition. 

Symptoms. In mild cases the slowly developing dropsy, with 
a?iccmia, and dysp?iosa, or simply shortness of breath, with weakness, 
are the only clinical phenomena present, the diagnosis being con- 
firmed by an examination of the urine. Usually, however, begins 
suddenly. Fever, with nausea and violent and persistent vomiting, 
dull pain over the kidneys, following the ureters ; frequent desire to 
urinate ; diarrhoea ; skin harsh and dry ; pulse quick, tense, and full. 
Soon dropsy appears, the eyelids and face become puffy and swollen, 
followed by general oedema of the extremities, scrotum, and abdo- 
minal walls. If the attack follow scarlatina, there are from the onset 
much greater pallor and general debility. 

UrcBmic symptoms may develop any time during the attack. 

The tcrine is of high specific gravity, 1025 to 1030, scanty, smoky 
(like beef washings) in color, due to the presence of blood. Albumin 
is present in large quantities, and the microscope reveals casts of the 
uriniferous tubules, blood corpuscles, uric acid, urates, oxalate crys- 
tals, and epithelium. The total amount of urea eliminated during the 
twenty-four hours is lessened from one-fourth to one-half. The 
amount of phosphates and chlorides is also lessened. 

Duration from one to four weeks. 

Complications. Pericarditis, pleuritis, pneumonitis, peritonitis, 
and acute urcemia, from retention and decomposition of urea in the 
blood. 

Diagnosis. The history, fever, scanty, smoky, albuminous urine, 
with dropsy beginning in the face, should prevent any error. 

Albumiiiuria may be confounded, on account of the presence of 
albumin in the urine, but lacks the clinical history, usually occurring 
in the course of some constitutional affection, as diphtheria, cholera, 
yellow fever, or erysipelas. 

Da Costa distinguishes between acute Bright's disease and acute 
nephritis by the last named "affecting only one kidney, by much 
greater pain and tenderness in the lumbar region, by the retraction of 
the testicle, and by the higher degree of febrile excitement. Then, too, 
the deeply colored urine which is voided contains little or no albumin." 

Prognosis. Favorable. Majority of cases recover under prompt 
treatment. Rarely passes into chronic Bright's disease. Urczmic 
symptoms add to the gravity of the prognosis. 
15 



170 PRACTICE OF MEDICINE. 

Treatment. Absolute rest in bed until all symptoms have disap- 
peared. A strictly milk diet is the most suitable, but if there is much 
depression and weakness, may add animal broths and oysters. No 
tea, coffee, or stimulants. Water can be used ad libitum. Cream of 
tartar lemonade is a useful as well as pleasant drink. Locally, dry 
cups over the kidneys, followed by poultices — a digitalis poultice 
being of great value. A poultice of jaborandi leaves and flaxseed, 
half and half, will increase the action of the kidneys. 

The bowels should be kept soluble with morning doses of salines 
or pulv. jalaptz co?np., Z) (4 Gm.), in water before breakfast, or 
elateriiwi, gr. yi (o.on Gm.), repeated p. r. n. Free action of the 
bowels assists in relieving the overtaxed kidneys, and conjoined 
with free diaphoresis seems almost indispensable in acute nephritis. 
Magnesii sulphas, in small and repeated doses, is a valuable cathartic 
in nephritis, as it acts upon the kidneys as well as the bowels. 

The most efficient diaphoretics are the hot-air bath or pack, or the 
wet sheet and blanket bath, stimulating the peripheral circulation, after 
free sweating has occurred, by rubbing with alcohol and water. For 
drugs, one of the very best is spiritus atheris nitrosi, rr^v-xxx (0.3-2 
Cc), according to the age. Extractum pilocarpi fluidum, rr^v-xxx 
(0.3-2 Cc), according to the age, every three or four hours, is an 
excellent diaphoretic ; but as it is generally conceded that pilocarpus 
acts better when administered subcutaneously, employ pilocarpines 
hydrochloras, gr. l /e (0.011 Gm.), repeated p. r. n., by the hypodermic 
method. Another valuable diaphoretic is vinum ipecacuanhce, rr\j- 
iij (0.06-0.2 Cc), every half hour or so ; combined with sweet 
spirits of nitre and neutral mixture it forms an excellent combination. 

Diuretics are of great value, indeed, often indispensable, in acute 
nephritis. Digitalis is the most reliable diuretic in this condition, and 
in the form of an infusion. The following formula of Millard's is 
suitable in the majority of cases : 

& . Tinct. digitalis, f.? ss I S- Cc 

Aceti scillae, .• . . f % iss 45. Cc. 

Spts. aetheris nitrosi, f^ij 60. Cc. 

SlG. — Teaspoonful every two to four hours, in water. 

The following combination has given excellent results : 

\\. Potassiiacetat., 7, iv 15. Gm. 

Inf. digital., f.^i'j 9°- Cc. 

Liq. potassii citratis, fjiij 9°- Cc. 

SlG. — Tablespoonful every two to four hours, in water. 



DISEASES OF THE KIDNEYS. 171 

Other reliable diuretics are digitalinum (cryst.), gr. T i n (0.00065 
Gm.), caffeines citrata, gr. ij-iv (0.13-0.26 Gm,), or sparteines sulphas, 
g r - l A- l A (0.02-0.03 Gm.). 

If ursemic symptoms develop, treat according to directions given 
in that section. 

As soon as the blood disappears from the urine, a course oiferrum, 
in the shape of Basham" s mixture, until albumin disappears and 
health is restored. The following is the formula of Basham's mix- 
ture : 

rjt . Liq. amnion, acetat. , f^ v j *8o. Cc. 

Acid, acetic, f 3 iij 12. Cc. 

Tinct. ferri chlor., f 3 v 20. Cc. 

Alcoholis, f % ij 60. Cc. 

Syrup., f,li y I2 °- Cc. 

Aquae, f^iv l 2 °- Cc. M. 

Sic. — Dose, f^j-f^j, well diluted. 

The addition of one minim (0.065 Cc.) spiritus glonoini to each 
dose of Basham's mixture increases its nephritic action. 

Dr. James Tyson, than whom there is no greater authority in 
nephritic conditions, strongly urges the use of infusum digitalis in- 
stead of the tincture. He also recommends, as an admirable diuretic 
combination, Trousseau's diuretic wine, viz.: 

$ . Junip. contus, £x 40. Gm. 

Pulv. digitalis, £ij 8. Gm. 

Pulv. sdllae, 3J 4. Gm. 

Vin. xerici, Oj 473. Cc. 

Macerate for four days and add 

Potassii acetatis, 5 iij 12. Gm. 

Express and filter. 

Sig. — Tablespoonful three times a day for an adult. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 

Synonyms. Chronic Bright's disease ; chronic croupous ne- 
phritis ; chronic tubal nephritis ; chronic albuminuria ; large white 
kidney/ 

Definition. A chronic inflammation of the cortical and tubular 
structure of the kidneys ; characterized by albuminous urine, dropsy, 
increasing anaemia, with attacks of acute urcsmia. 



172 PRACTICE OF MEDICINE. 

Causes. Rarely follows the acute form, but in ever so many- 
cases the etiology is unknown, and in the vast majority of cases it is 
primarily chronic or subacute ; syphilis ; chronic malaria ; alcoholic 
excesses ; chronic mercurialism ; lead poisoning ; opium habit ; pro- 
tracted suppuration; phthisis; hepatic disorders; pregnancy; some 
undetermined nervous condition. 

It is a disease of the young, rarely occurring after forty. Princi- 
pally occurring in males. 

Pathological Anatomy. A large white, or yellowish white, 
smooth kidney, often twice the normal size. The capsule is nowhere 
adherent to the organ. Upon section, considerable tumefaction of 
the cortical substance and the rarity of vascular striae are recognized. 
The medullary substance shows no appreciable alteration, its color 
being normal. The convoluted tubes are irregularly dilated and 
thickened, and filled with broken-down granulated epithelium and 
fibrinous casts. In pronounced cases there is fatty degeneration of 
the tubular epithelium. 

" The intertubular matrix is greatly thickened — a change due to 
hyperplasia of the connective-tissue elements, to the migration of the 
white corpuscles and their subsequent multiplication and fatty trans- 
formation, and to a quantity of fluid exudation, the product of the 
increased pressure in the veins." 

Symptoms. The onset is gradual and insidious, and the affec- 
tion is seldom recognized until the appearance of dropsy, which, 
beginning under the eyes and in the face, extends all over the body, 
causing dyspnoea from ascites or hydrothorax, although in many cases 
the dropsy may be a late symptom, the patient becoming pale, debili- 
tated, and suffering from cardiac palpitation, increasing dyspnoea on 
exertion, and vomiting, all gradually developing without apparent 
cause ; also headache, vertigo, and defective vision. The urine is 
scanty, high-colored, albuminous, and under the microscope showing 
hyaline and granular tube casts, granular epithelium, and if fatty de- 
generation occur, fatty tube casts and oil globules. The increase above 
the normal amount of the urine, as the disease progresses, must not be 
forgotten when the specific gravity is low, 1.010-1.015, an d tne quan- 
tity of albumin is increased. The normal constituents of the urine, 
and particularly urea, are diminished. Irritable bladder is a very 
constant symptom, beginning very early in course of the disease. In 
the hemorrhagic form the urine almost constantly contains blood. 






DISEASES OF THE KIDNEYS. 173 

Ancemia is pronounced, from the large waste of albumin. Gastro- 
intestinal disorders and various neuralgic pains are common occur- 
rences. Cardiac hypertrophy is of common occurrence. Bronchial 
catarrh, with slight cedema of the larynx, causing husky voice, are 
frequent complications. Amaurosis, the result of neuro-retinitis, 
occurs in a greater or less degree in all pronounced cases. Urcemic 
symptoms occur and especially ur&mic asthjna (renal asthma). 

Da Costa calls attention to a temporary loss of vision, soon returning 
and again recurring, in a well marked case of this disease. 

Complications. Pneumonia, pleuritis, pericarditis, peritonitis, 
meningitis, and cardiac hypertrophy. 

Prognosis. Not unfavorable, unless the urine persistently con- 
tains a large number of fatty tube casts and oil globules. Relapses are 
frequent, but many complete (?) recoveries are recorded. I have seen 
four apparent recoveries, one after twelve months' duration, another 
after two years' duration, and still another after five years' duration, 
no return showing itself after two years. The secondary contraction 
of the kidneys must always be kept in mind, the particular symptoms 
of which are increased flow of low specific gravity, urine with small 
amount of albumin, and hypertrophy of left ventricle, with accen- 
tuated aortic second sound. 

Treatment. It is to be borne in mind that the course of a case 
of chronic Bright's disease is not continuously downward ; periods of 
remission often follow the most aggravated symptoms, the patier.t 
and his friends being buoyed with the hope of an early recovery, 
when, suddenly, an attack of acute uraemia terminates life. 

A patient with chronic Bright's disease should, as far as possible, 
be relieved from all cares of business and spend a goodly portion of 
time in bed. 

The diet is of prime importance. It may consist of an absolute 
milk regimen, pure, or prepared as most palatable, or an exclusive 
lean meat diet, prepared by finely chopping, removing all fibrous and 
fatty portions, boiled quickly, salted to taste, and served hot — the so- 
called " Salisbury steaks." The use of half a pint of hot water, 
acidulated with lemon, before each meal is valuable. 

The use of diaphoretics and hydragogue cathartics are only indi- 
cated when the dropsy is marked, the skin harsh and dry, the urinary 
secretions scanty, and uraemic symptoms are threatening. 

Diuresis should be promoted, if the secretion of urine is scant, by 



174 PRACTICE OF MEDICINE. 

digitalis, caffeincz citrata, or sparteines sulphas, internally or hypo- 
dermically, or spiritus glonoini, and dry cups and poultices over the 
loins, and the use of the normal salt solution slowly injected into the 
bowels. The following is a good combination for scanty urine and 
costive bowels : 

Be. . Hydrargyri chlor. mitis, 

Pulv. scillee, 

Pulv. digital., aa gr. j aa .065 Gm. 

F pil. 

SiG. — Three times daily for a few days. 

An excellent plan to promote diuresis and diaphoresis in all forms 
of nephritis is by the use of pilocarpus locally. I have used the fol- 
lowing ointment for several years with invariable success : 

R . Pilocarpine nitrat., gr. j-iij .065-2 Gm. 

Ung. petrolei, |jj 30. Gm. M. 

SiG. — Apply piece size hickory-nut over dorso-lumbar region-, night and 
morning, covering surface with layer of cotton or gauze. 

Iron is preeminently the drug for this variety of Bright's disease, 
using the tinctura ferri chloridum. Large doses are not needed. 
Combined with spiritus aetheris nitrosi or in the form of Basham's 
mixture, makes an excellent combination for the ferrum ; one minim 
(0.06 Cc ) spiritus glonoini added to each dose of the ferrum com- 
bination is useful. 

The a?i<zmia is to be treated by oleum morrhuce, arsenicum, and 
ferrum, an excellent formula for the latter being — 

$. Strychnine sulph., gr. ^ .016 Gm. 

Tinct. ferri chloridi, f 3 ij 8. Cc. 

Acidi acetici purse, fzj 4. Cc. 

Curacose alboe, f 5 j 30. Cc. 

Liq. ammonii acetat., . . adfjvj 180. Cc. M. 

SiG. — Tablespoonful every five hours, followed by a glass of cold water. 

To check the waste of albwnin, a difficult matter, the following 
remedies have been used with more or less success : ergota, quinina 
sulphas, acidum gallicum, sodii benzoas, tinctura cantharidis, or 
potassii iodidum. 

For dropsy, purgatives, such as pulvis jalapcE compositus, magnesii 
sulphas, and alkaline mineral waters or the vapor baths, or pilocar- 
pines hydrochloras, gr. yi (0.008 Gm.), repeated if not much cardiac 
depression, or combining pulvis ipecacuanhce et opii, gr. iij (0.2 Gm.), 



DISEASES OF THE KIDNEYS. 175 

with potassii nitras, gr. iij (0.2 Gm.), every two or three hours, 
or diurelin, gr. xx (1.3 Gm.), after meals; what is most valuable is 
the hot-air bath ox pack. If there be great distention of the serous 
cavities, interfering with the respiration, the aspirator should be used. 
Puncture of the skin may be necessary at times, and it is well 
accomplished with an ordinary cambric needle. 

Cases due to syphilis, if the loss of renal structure is slight, are 
cured by a course of hydrargyri corrosivum chloridum and potassii 
iodidum, with oleum morrhucz. 



INTERSTITIAL NEPHRITIS. 

Synonyms. Chronic Bright's disease ; sclerosis of the kidneys ; 
contracted kidney ; small red kidney ; gouty kidney. 

Definition. An inflammation of the intervening connective 
tissue of the kidney, chronic in its progress, resulting in an induration 
or hardening, with contraction of the organ ; characterized by the fre- 
quent voiding of large amounts of pale, albuminous urine, of low 
specific gravity, disorders of the gastro-intestinal canal and nervous 
system, and a strong tendency to cardiac hypertrophy and changes 
in the vessel. Cases of interstitial nephritis are not uncommon in 
which albumin is never detected in the urine. 

Causes. A disease of middle life, from forty to sixty years. 
Gout a common cause ; lead cachexia ; syphilis ; alcoholism ; opium 
habit ; following chronic cystitis and chronic gonorrhoea ; long-con- 
tinued worry, anxiety, or grief; alterations in the renal ganglionic 
centres (Da Costa and Longstreth). Hereditary influence (Tyson), 
secondary to chronic cardiac disease. Hepatic disorders, as the 
functions of the liver and kidneys are closely related. A functional 
disorder of the liver, if not checked, leads to organic kidney disease. 

" Renal degeneration is a consequence of the long-continued 
elimination of products of faulty digestion through the kidneys." 
Uric acid is a nephritic irritant. 

" There is a tendency to overgrowth in the interstitial tissue of the 
kidney, as of other organs, in old age. Hence the term senile atrophy 
of the kidney. It is not safe, therefore, to call every instance of atro- 
phied kidney met in the post-mortem room a case of interstitial 
nephritis." (Tyson.) 

Pathological Anatomy. The kidneys are increased in size. 



176 PRACTICE OF MEDICINE. 

The capsule is thickened, opaque, and adherent. The surface of 
the kidney is granular, with cysts of various sizes, of transparent color, 
scattered irregularly over the surface. On section the tissue of the 
kidney is tough and resistant. The cortical portion is thin, from 
atrophy, being only a line or two in thickness. The connective tissue 
is greatly thickened, compressing the tubules into mere threads, the 
glomeruli being grouped together in bunches, owing to the wasting of 
the intermediate tubes. The color varies from a darkish brown to a 
yellowish gray, according to the amount of blood in the organ. 

The left side of the heart is hypertrophied, and there is also hyper- 
trophy of the muscular fibre of the arterioles throughout the body; 
if the case is protracted, the hypertrophied tissues undergo fatty 
degeneration. Cardiac degeneration with arterio-capillary sclerosis or 
fibrosis is associated with advanced nephritis. 

In many cases there occur fatty degeneration of the retinal tissues, 
or sclerosis of the nerve-fibre layer, changes which are termed 
retinitis albuminuria. 

The "ganglionic centres " undergo fatty degeneration and atrophy 
(Da Costa and Longstreth). 

Apoplexy is a frequent termination of interstitial nephritis, the rup- 
ture of a cerebral vessel suggesting it to be a disease of degeneration. 

Symptoms. Onset insidious, and often marked alterations in 
the kidneys, heart, and vessels have occurred before the disease is 
recognized. There are no characteristic early symptoms in the 
majority of cases, the disease being apparently latent until some 
special outbreak causes a more thorough examination of the patient, 
when interstitial nephritis is detected. 

Any of the following symptoms may first attract attention : Frequent 
micturition ; increased amount of urine; fifty to ninety ounces, acid, 
and of a pale color; low specific gravity, 1005-1015; containing a 
small amount of albiwiin, which may be absent for days ; occasional 
epithelial cells and hyaline and pale granular casts. No dropsy, but 
a little puffiness and oedema of the conjunctives — the Bright's eye. 
Disorders of vision. Forcible cardiac action with high arterial 
tension, due to left cardiac hypertrophy, which is an almost constant 
condition. Attacks of vertigo ; headache ; pulsations in the head, 
neck, and other parts of the body, and, as the disease progresses, 
cardiac distress, dyspnoea, and palpitation occur. A reduplication 
of the first cardiac sound is common ; the second aortic sound is 



DISEASES OF THE KIDNEYS. 177 

accentuated and the pulse is hard and resisting, indicating high 
tension and thickening. " Sclerosis is distinguished from tension by- 
obliterating the blood current by pressure and feeling the artery 
beyond. The sclerosed vessel continues tangible, that of high 
pressure disappears." (Tyson.) Disordered vision; attacks of epistaxis 
and disordered stomach. Progressive anaemia is a frequent symptom, 
with a sense of great weakness. Any of the following symptoms, the 
result of urczmza, may occur : Persistent dyspepsia, occasional vom- 
iting, regardless of food ; headache, vertigo, and stupor, or drowsiness ; 
violent itching of the skin ; tremors, convulsions, epileptic seizures, 
or apoplectic attacks. 

The body weight declines, the skin is dry and scurfy, the strength 
fails, and shortness of breath on exertion is present. 

Albumin may be absent from the urine throughout the entire course 
of interstitial nephritis, and casts be only occasionally detected after 
many trials, and yet the disease progresses to a fatal termination. 

Towards the termination of the disease the urine diminishes in 
quantity, specific gravity increases, and the casts increase in number 
and variety, dark granular and blood casts often being observed. 

The termination is usually by convulsions, coma, and death. 

Complications. Bronchitis ; pneumonitis ; pleuritis ; pericar- 
ditis ; cardiac hypertrophy. Pericarditis is always fatal. 

Diagnosis. Interstitial nephritis is most likely to be confounded 
with parenchymatous nephritis. The following table from Millard 
presents the most important point of difference between the two : 

In Chronic Croupous Nephritis, In Chronic Interstitial Ne- 
phritis, 

The urine is always albuminous. Urine not constantly albuminous. 

Urine usually scanty. Urine usually abundant. 

Dropsy and cedema almost always Dropsy seldom or never present ; 

occur. sometimes slight cedema. 

Hypertrophy of the heart seldom Some hypertrophy of heart, with 

exists. increased arterial tension, almost al- 
ways present. 

Specific gravity of urine usually Urine generally of a light color 

higher than the normal. Urine darker and low specific gravity, 
and with less of a soapy appearance 
than in chronic interstitial nephritis. 
16 



PRACTICE OF MEDICINE. 



In Chronic Croupous Nephritis, 

Unemic symptoms less frequent 
than in chronic interstitial nephritis. 

Epistaxis and cerebral hemorrhages 
rare. 

Occurs most frequently before the 
age of forty. 

Blood corpuscles and connective- 
tissue shreds more frequently found 
in chronic croupous nephritis. 



Casts more numerous and in greater 
variety than in chronic interstitial 
nephritis; waxy, granular, fatty, and 
hyaline casts occurring. 

Epithelia from the kindey and pus 
corpuscles more numerous than in 
interstitial nephritis. 

Urates and phosphates predomi- 
nate ; oxalates rare. 

Albuminous retinitis rare. 

Gangrenous erysipelas and phleg- 
monous swellings more common ; also 
dyspepsia and ancemia. 

Visceral complications, as pneu- 
monia, pleuritis, pericarditis, and 
bronchitis, not uncommon. 

Diarrhoea sometimes. 

Cirrhosis of liver rare. 

Atheroma of arteries rare. 



In Chronic Interstitial Ne- 
phritis, 

Ursemic symptoms are met with in 
their most pronounced form, and in 
severe cases usually oceur. 

Epistaxis and cerebral hemorrhages 
frequent. 

Occurs most frequently after forty. 

Absent in chronic interstitial ne- 
phritis. 

Development more gradual, the 
health of patient often le.ss impaired, 
and duration longer than in chronic 
croupous nephritis. 

Casts rare, the hyaline variety be- 
ing most frequently met with. 



Kidney epithelia and pus corpus- 
cles scanty, and occasionally absent. 

Oxalate of lime almost always oc- 
curs. 

Albuminous retinitis common. 



Visceral complications rare. 



Cirrhosis the most frequent hepatic 
lesion. 

Atheroma common. 



Prognosis. Pursues a very chronic course ; cases recorded under 
observation eleven years. If the case is seen in its incipiency, a 
cure is possible, but as a rule we say the prognosis is unfavorable. 



DISEASES OF THE KIDNEYS. 179 

Treatment. To prolong life is the great indication, as the dis- 
eased kidneys cannot be restored. 

Regulated diet is of first importance. The eliminating function 
of the kidney being lessened, the diet must be one as free from urea 
as possible. Milk should be the chief and for long periods the only 
nitrogenous food used; plain, skimmed, and diluted with Vichy, 
Apollinaris, and Seltzer waters. Eggs, soft-boiled or poached in milk. 
Occasionally chicken broth. The remainder of the diet should come 
from the vegetable list. Avoid alcoholic stimulants. 

A daily warm or hot bath is valuable, but under no consideration 
should cold or sea bathing be allowed. Warm clothing, and protect- 
ing the body from cold and damp is most important. 

Rest of mind and body as far as circumstances will permit. 

The bowels should be kept regular and soluble with salines or cas- 
cara sagrada, which is said to be a valuable eliminator of urea ; until 
the urine becomes scanty diuretics are not indicated. Ferrwn 
should only be used for the anaemia. 

For the nephritic, cardiac, and vessel changes there is no one 
remedy comparable with niiro-glycerinum, or sfiiritusglonoiiii, in doses 
of rr\j (0.06 Cc), which equals gr. -^ (0.00065 Gm.), repeated three 
to six times a day. An excellent combination in the early stages of 
interstitial nephritis is : 

R . Hydrargyri chloridi corrosiv., . . gr. j .065 Gm. 

Aurii et sodii chloridi, gr. j .065 Gm. 

Ferrireduct., gr. xxx 2. Gm. 

Spts. glonoini, TTi^xxx 2. Cc. 

Ft pil. no. xxx. 

SiG. — One after meals. 

Potassii iodidum has been recommended to prevent or hinder the 
connective-tissue growth. If syphilis can be traced as the causative 
factor, it should be given a trial. 

For. the urczmic symptoms the reader is referred to that subject. 

For the gastric symptoms the following is an excellent formula : 

R • Pepsin, purse, ........ gr. xxxij 2. Gm. 

Acidi hydrochloric, dil., . . . . f.^ss 15. Cc. 

Glycerini, f^j 30. Cg. 

Aqu^ chloroformi, .... ad f^iij 90. Cc. M. 

Sic;. — One teaspoonful at meal-time, well diluted. 



180 PRACTICE OF MEDICINE. 

AMYLOID KIDNEY. 

Synonyms. Chronic Bright's disease ; waxy kidney ; lardaceous 
kidney. 

Definition. A peculiar infiltration into, or a degeneration of, the 
structure of the kidney, from the deposit of an albuminoid material, 
having a superficial resemblance to molten wax or boiled starch. Simi- 
lar changes occur in the liver, spleen, intestines, and other organs. 

Causes. The chief cause is prolonged suppuration, especially of 
the bones ; coxalgia ; syphilis ; cancer; phthisis. 

Pathological Anatomy. The kidney is uniformly enlarged. 
It presents a pale, glistening, translucent appearance, and has a 
doughy consistency. On section, the surface is homogeneous, 
anaemic, and whitish. The deposit occurs along the renal vessels and 
in the vascular tufts of the glomeruli, progressing until all parts of the 
organ are infiltrated. When the organ is thus infiltrated, the proper 
structure undergoes an atrophic degeneration, the result of pressure. 

The reaction with iodine and sulphuric acid affords a certain test 
of the amyloid deposit. Brush over a section of the affected kidney 
a solution of iodine with iodide of potassium in water, when a 
mahogany color will be produced, and if diluted sulphuric acid is now 
added, a violet or bluish tint results. A very pretty reaction is to take 
a one per cent, solution of anilin violet, which strikes a red or pink 
color with the amyloid material, while the unaltered tissues are 
stained blue, making a beautiful contrast. 

Similar changes occur in other organs of the body. With the amy- 
loid change may be associated either parenchymatous or interstitial 
nephritis. 

Symptoms. Associated with wasting are cedema of the lower 
extremities and ascites, with an increased fiow of urine, pale, watery, 
and of low specific gravity, containing albumin and hyaline casts, 
which are transparent. If the amyloid change be associated with 
other forms of renal change, the urine will show the characteristics of 
such condition. A profuse, watery, and persistent diarrhoea caused 
by the amyloid changes in the intestinal canal. 

Diagnosis, Differs horn parenchymatous nephritis in its clinical 
history, and the fact of its always being associated with a suppurating 
disease. 

From interstitial nephritis, in its history, character of the urine, 



DISEASES OF THE KIDNEYS. 181 

absence of uraemia, cardiac hypertrophy, changes in the vessels, and 
the fact of its association with suppurating diseases and similar 
changes in other organs. 

Prognosis. Controlled by the suppurating disease with which it 
is associated ; the termination, when the amyloid change is fully de- 
veloped, is unfavorable, death occurring within a few months, or, 
under favorable conditions, not for one or more years. 

Treatment. Sustaining and symptomatic in character. Gener- 
ous diet and the persistent use of ferri iodidum, alternating with am- 
monii chloridu?n and oleum morrhuce. 

If caused by syphilis, a thorough course of potassii iodidu?n, ferri 
iodidum, and hydrargyri corrosivum chloridum, with oleum morrhucE. 

If of syphilitic origin, the plan of Keyes (Dr. E. L.) is to be com- 
mended : "A case treated from the first should receive mercury 
continuously in small doses, gr. ^ to gr. g 1 - (0.0015-0.002 Gm.), for 
a period not less than two and a half years, or, in any event, until 
at least six months have passed after the entire disappearance of 
the clearly syphilitic symptoms." 



PYELITIS. 

Synonyms. Suppurative nephritis ; pyelo-nephritis. 

Definition. An acute catarrhal inflammation of the pelvis of the 
kidney ; the term pyelo-nephritis is used when suppurative inflamma- 
tion is superadded to the catarrhal inflammation. The disease is 
characterized by lumbar pains, irritability of the bladder, the urine 
neutral or alkaline in reaction and milky in appearance; \i pyelo- 
nephritis occur, symptoms of hectic fever and exhaustion are added, 
the urine containing pus. 

Causes. Cold or exposure ; cystitis ; obstruction of the ureters 
by renal calculi ; pressure from a tumor; prolonged use of bromides 
and other irritative drugs ; rheumatism ; sequelae of infectious diseases. 

Pathological Anatomy. The inflammation is catarrhal ; it is 
characterized by injection of the mucous membrane of the pelvis of 
the kidney, wkh slight extravasations of blood ; relaxation and soft- 
ening, shedding of the epithelium, and the subsequent discharge of 
mucus and pus. If the morbid condition has existed for some time, 
the kidneys, one or both, are in a process of suppuration ; they are 



182 PRACTICE OF MEDICINE. 

enlarged, deeply congested, except where suppuration is proceeding, 
when they are of a yellowish-white color — pyelo-nephritis. Pus is 
constantly forming, and if there be no obstruction, flows away with 
the urine ; should there be an impediment to its escape, pus accumu- 
lates in the pelvis of the kidney, causing its distention, giving rise 
to the condition known as pyelo-nephrosis. The pressure caused by 
the obstruction finally leads to destruction of the entire organ, a 
mere sac, or renal cyst, remaining. 

Symptoms. If caused by cystitis, symptoms of this condition 
occur first; if from renal calculi, its characteristic symptoms precede 
those of pyelitis. 

Begins by chilliness, feverishness, lumbar pains following the 
course of the ureters, frequent micturition, the urine milky in appear- 
ance when voided, acid or neutral in reaction, and depositing a 
copious sediment, whitish or yellowish-white in color, containing 
only a small amount of albumin, no more than is due to the pus. 

Cases of pyelitis due to renal calculi frequently show hemorrhages ; 
the urine bloody after some extra exertion. 

If pyelo-nephritis follow, symptoms of pyemia supervene, to wit: 
fever, typhoid in character, low, muttering delirium, subsultus tendi- 
num, stupor, decline in strength, and loss of flesh, with perhaps a 
tumor in the lumbar region. 

If both kidneys are affected, uramic symptoms are frequent. 

Diagnosis. From cystitis, by history, lumbar pains, and acidity 
or purulent urine, the urine in cystitis being always alkafaie. A 
microscopical examination of the urine will aid the diagnosis very 
much. 

Perinephritis, a disease of the loose tissue, around about the kid- 
neys, terminating in abscess, causing lumbar pain, increased by 
motion or pressure, hectic fever, sense of fluctuation over kidneys, 
the urine remaining normal. 

Prognosis. Simple cases, where no obstruction to flow of pus, 
recover in a week or ten days. If obstruction of the ureter, the prog- 
nosis is grave. Suppurative cases unfavorable. 

Treatment. Rest in bed. Milk diet. Free use of water to 
dilute the urine, and free diaphoresis. Quinifics sulphas to keep down 
temperature, prevent formation of pus, and maintain the powers of 
life. 

To change the character of the secretion, Prof. Da Costa strongly 



DISEASES OF THE KIDNEYS. 183 

recommends pix liquida ; other remedies are oleum santali, copaiba, 
eucalyptol, ierebinthina, and cubeba. I have seen excellent results 
from a prolonged course of the Buffalo Lithia Springs water or the 
Rockbridge Alum Springs water of Virginia. 

For renal hemorrhage, alumen, gr. xx (1.3 Gm.), repeated p. r. n., 
is successful. 

If abscess results, aspiration, quinince sulphas, and stimulants. Ex- 
tirpation of the diseased kidney has been followed with fair health. 



ACUTE UREMIA. 

Synonyms. Uraemic poisoning ; uraemic intoxication ; uraemic 
coma; uraemic convulsions. 

Definition. A group of nervous phenomena, which occasionally 
develop during the course of acute or chronic Bright's disease, and 
other maladies, the result of the retention or accumulation in the 
blood of an excrementitious material, supposed to be urea, the flow 
of urine being either normal, lessened, or increased. 

Causes. Suppression of urine, from acute or chronic Bright's 
disease, probably more frequent in chronic parenchymatous nephritis ; 
cystic, tubercular, or cancerous kidney ; the puerperal state; opera- 
tions on the uterus bladder, urethra, or rectum. 

Symptoms. Uraemic intoxication is the result of the failure of 
the kidneys to perform their normal function of eliminating some one 
or all of the poisonous elements of the urine. 

The toxaemia may develop suddenly, by a convulsive seizure fol- 
lowed by coma, or slowly and gradually. Usually the attack is pre- 
ceded by a decrease in the urinary secretion and slight or marked 
cedema in various parts of the body ; although it must be borne in 
mind that in rare instances, during, or immediately prior to, the ap- 
pearance of the uraemic phenomena, the normal urinary flow has 
been largely exceeded. 

The acute outbreak may manifest itself in a variety of ways. 

Gastro-intestinal variety : The patient suddenly experiences attacks 
of vertigo, pallor of face, nausea and vomiting, with/ever, the tempera- 
ture varying between ioo° and 103 , pulse tense and rapid, respiration 
hurried, and the urine scanty with low specific gravity ; unless symp- 
toms are promptly relieved, convulsions may occur, followed by coma 



184 PRACTICE OF MEDICINE. 

and death, or drowsiness supervenes, followed by coma, which is really 
nothing but a profound sleep. Rarely an acute maniacal outbreak 
follows the gastro-intestinal symptoms. 

Convulsive variety. Without any appreciable prodromes, epilepti- 
form convulsions, with or without loss of consciousness. The convul- 
sions may consist of a single paroxysm, or a succession of fits may fol- 
low one another at intervals of a few minutes or several hours, the 
patient in a condition of more or less profound insensibility during 
the intervals. The fits closely simulate true epilepsy. In this variety 
the temperature is high, from 103 to 106 or more, the pulse rapid, 
with or without tension, the respirations quickened. Coma followed 
by death is a very common ending of this variety of uraemia, or 
after a profound sleep of hours the patient gradually recovers his 
usual health. Alcoholic excesses are responsible for many of these 
attacks. , 

Cerebral variety, or urcemic coma. Develops gradually, with an 
increasing drowsiness, associated with headache and irritability of 
temper (mild mania). Nausea, vomiting, and rise of temperature, 
often reaching 105 , rarely 107 , with rapid, full pulse, or the patient 
may fall suddenly into a condition of profound coma, the symptoms 
closely resembling an apoplectic stroke, excepting the high tempera- 
ture. Uraemic coma is always accompanied with rise of temperature 
and stertor. " The stertor is peculiar ; it is not the ' snoring ' of apo- 
plexy, but a sharp, hissing sound produced by the rush of expired air 
against the teeth or hard palate." (Loomis.) The respirations are 
accelerated, the pulse rapid but minus tension. This variety may 
suddenly terminate fatally with a convulsion, or a deepening coma 
with prostration and cold, wet skin, with oedema of the lungs, or, 
rarely, gradual recovery. 

Diagnosis. Uraemic conditions closely resemble a number of 
conditions in which convulsions and coma are prominent symptoms. 
Much valuable assistance is obtained by a knowledge of the condition 
of the kidneys. Always obtain a specimen of urine at once and sub- 
ject to an albumin test at least. 

Another valuable aid is the temperature record. I believe acute 
outbreaks of uraemia are always associated with arise of temperature. 
The temperature is the result of the irritation of the heat-centres and 
not due to an increased arterial pressure. 

Cerebral apoplexy may be mistaken for uraemic coma, or the re- 



DISEASES OF THE KIDNEYS. 185 

verse. The chief points of distinction are that in the latter the attack 
is usually in patients suffering from dropsy, and that the coma is not 
sudden in its appearance, but is generally preceded by other nervous 
phenomena, such as headache, vertigo, dimness of vision, obstinate 
vomiting, and convulsions. Again, the urcsmic stertor is a sharp, 
hissing sound, while that of apoplexy is " snoring." Apoplexy is fol- 
lowed by paralysis ; ursemic coma is not. 

An epileptic seizure is preceded by a sharp cry and extreme pallor 
of the face, the countenance being dusky in ursemic convulsions. 

Prognosis. An attack of acute uraemia is always a very grave 
condition. The prognosis depends upon the amount of retained 
poison, the length of time it has been retained, and the condition of 
the organs of elimination. 

Treatment. Promptness and thoroughness is the essential point 
in the treatment of a uraemic outbreak. 

For the gastro-intestinal variety, put patient to bed and administer 
the magnesium sulphate enema given below, and order either caffeines 
citrala,gr. iij (0.2 Gm.), every three hours, or the spartein and pilo- 
carpine mixture mentioned below. As soon as the secretions have 
been started, give one of the following powders every two hours until 
a dozen or more are used, followed by Hunyadi Janos water: 

ft. Hydrargyri chlor. mitis, . . . . gr. %- l /2 .016-.032 Gm. 

Sodii bicarb , gr. ij .130 Gm. 

Pulv. ipecacuanb.se, gr. y^ .oil Gm. M. 

Ft. cbart. No. j. 

For the convulsive or cerebral variety, the indications are : first, 
to arrest the nervous phenomena; secondly, to promote elimination. 
Prof. Loomis has succeeded in meeting both of these conditions by 
hypodermic injections of morphince sulphas , gr. l /6-}i- l /2 (0.01 1 -0.016- 
0.032 Gm.), repeated, if required, every two hours. He says : " The 
most uniform effect of morphine so administered is, first, to arrest mus- 
cular spasms; second, to establish profuse diaphoresis ; third, to facili- 
tate the action of cathartics and diuretics, especially the action of 
digitalis." 

Following the injection of morphina, diaphoresis should be pro- 
moted by means of the hot-air bath, or the hot wet pack, or the hypo- 
dermic use of pilocarpines hydrochloras, gr. -r%- l A>~% (0.005-0.01 1- 
0.016 Gm.), provided no counter-indication to its use exists, or using 
at the same time frequent doses of caffeines citrata, gr. iij (0.2 Gm.). 



186 PRACTICE OF MEDICINE. 

The following combination has given excellent results in a number 
of cases when the patient was able to swallow : 

&. Sparteine sulphat., gr. iv .265 Gm. 

Pilocarpine hydrochlor., .... gr. j .065 Gm. 

Infus. digital. , f^ij 60. Cc. M. 

SiG. — Teaspoonful every half hour, hour, or two hours until effect. 

Spiritus glonoini added to the above combination is valuable. 
If patient is unable to use the medicine by stomach, the same drugs 
can be used by the hypodermic method, using digitalinae cryst. : 

rjt . Digitalinae cryst. , gr. -^V .001 Gm. 

Pilocarpine hydrochlor., . . . . gr. J4 .016 Gm. 

Sparteine sulph., gr. y z .032 Gm. 

Aquedestil., rr\xv . I. Cc. M. 

Sig. — As dose p. r. n. 

Or— 

i£ . Pilocarpine nitrat., gr. ij .13 Gm. 

Unguent, petrolei, ....... f t ^j 30. Gm. M. 

SiG. — Apply (rubbed) bis die over kidneys. 

I have never observed the alarming symptoms of depression men- 
tioned by some observers from the careful use of pilocarpus. 

The production of free diaphoresis alone must not mislead, for 
unless the sweat contains urea or its products it is only depressing, 
and the clinical fact is that in uraemia the eliminating function of 
the skin as well as of the kidney is in abeyance. 

The convulsions are rapidly controlled by inhalations of chloroform 
(although the after symptoms are badly influenced by the drug), or 
the internal or rectal administration of full doses of chloral, or by a 
free venesection. Indeed, venesection is too much neglected in condi- 
tions of coma and uraemic convulsions. It not infrequently happens 
that upon opening a vessel the blood does not flow, or but a few drops 
slowly flow from the wound. If this obtains it is almost immediately 
changed by a hypodermic injection of amyl nitrite, rt\,v (0.3 Cc.) with 
spiritus anvnonice aro?naticus t TT^xv (i Cc). 

Diuresis is promoted by infusum digitalis, dry or wet cupping, 
poultices over the loins, and hot compresses of infusum digitalis over 
abdomen, pilocarpus rubbed over the kidneys, or caffeince cilrata, or 
sparteines sulphas, or spiritus glonoini. The injection of the nor- 
mal salt solution, 3j : Oj (4 Gm. : 473 Cc), into the bowel every 



DISEASES OF THE KIDNEYS. 187 

hour or two, and by hypodermoclysisinto the loose connective tissue, 
promotes diaphoresis and diuresis. Excellent results have been ob- 
tained in uraemia with scanty urinary secretion and in other condi- 
tions with scanty urine with diuretin (a mixture of salicylate of soda 
and theobromin) in gr. xx-xxx (1.3-2 Gm.) in an ounce of water 
every two or four hours. 

Catharsis is best promoted by elaterium, gr. T V~i (0.005-0.008 Gm.), 
or an Epsom salts enema : 

]£ . Magnesii sulph., Jfij 60. Gm. 

Glycerini, %] 30. Cc. 

Aquae bul., . giv 120. Cc. M. 

As enema. 

The febrile reaction does not call for antipyretics. It is one of 
the nervous phenomena of uraemia, and is controlled by the means 
employed to eliminate the poison. 

If symptoms of collapse develop, with cold, clammy skin, feeble, 
rapid pulse, and superficial respirations, at once administer atrofiin<z 
sulphas, gr. ¥ J ¥ (0.001 Gm.), repeat p. r. n., and strychnines sulph., 
g r « ¥2~tV (0.002-0.004 Gm.), repeated p. r. n., with tt\,ij (0.12 Cc.) 
spiritus glonoini, and bathe surface with hot water and alcohol. 

Of late, sodii benzoas, gj-ij (4-8 Gm.) during the twenty-four hours, 
has been lauded as almost a specific in uraemic intoxication. Under 
the action of this remedy the paroxysms lessen in severity, the inter- 
vals grow longer, and the convulsions after a time cease entirely. 
Profound sleep is induced by it, and during this the cerebral functions 
are restored. When albuminuria exists, a marked diminution occurs 
in the quantity present, or the albumin disappears entirely. 

Milk, in as large quantities, diluted as can be borne, should be the 
diet. The attack broken, the treatment resolves itself into that of the 
nephritic affection causing it. 



RENAL CALCULI. 

Synonyms. Nephrolithiasis ; gravel ; renal colic. 

Definition. Renal calculi are concretions formed by the precipi- 
tation of certain substances from the urine, around some body or sub- 
stance acting as a nucleus. 



188 PRACTICE OF MEDICINE. 

Their presence may not be recognized until one or more attempts to 
pass along the ureters, when an attack of renal colic results ; or, by 
irritation,//*////* is produced; or, more rarely, they are voided by 
the urine without exciting any symptoms. 

By gravel 'is meant very small concretions (sand), which are often 
passed in the urine in large numbers. 

Causes. Occur at all ages ; frequent at forty to fifty years of age. 
Males are more liable than females. A special liability seems to 
exist in some families, but the precise etiology of calculi is not yet 
determined. 

Varieties. I. Uric acid, as calculi and gravel, and especially 
associated with the gouty diathesis. 

2. Urates, chiefly urate of ammonium ; nearly always in childhood, 

3. Oxalate of lime or mulberry calculus ; characterized by hardness, 
roughness, and very dark color. 

4. Phosphatic calculi form as frequently in the bladder as in the 
kidney, and present a chalky or earthy appearance. 

5. Alternating calculi, consisting of alternate layers of two or more 
primary deposits. 

Anatomical Characters. In structure, a urinary calculus 
usually consists of a central nucleus, surrounded by the body, and 
outside of all there may be a phosphatic crust. The nucleus may or 
may not be of the same material as the rest of the stone, sometimes 
being a foreign body, mucus, or blood. 

A section generally shows a stratified arrangement, or it may be 
partly or completely radiated. 

Symptoms. Many individuals have renal calculi and have no 
suspicion of their presence until an attack of renal colic occurs. 

The following signs indicate a renal stone : pain in back, princi- 
pally in either dorso-lumbar region with tenderness; renal hemor- 
rhage (hasmaturia), always a valuable symptom ; slight albuminuria, 
but no pus, with a few hyaline casts — these are long and narrow ; 
urine of high specific gravity is an important clinical symptom ; in- 
flammation terminating in abscess, pyelitis or pyelo-nephritis, cystitis, 
or renal colic. 

The symptoms of reiial colic begin abruptly, by severe, agonizing, 
pain in the lumbar region following the ureters into the corresponding 
groin and thigh. Pain and retraction of the corresponding testicle ; 
also of glans penis. Face pale and. features pinched, the surface cold 



DISEASES OF THE KIDNEYS. 189 

and damp. Irritability of the bladder, the urine passing in drops 
containing some blood. So severe is the pain at times that the 
patient may faint or pass into unconsciousness, or have a general 
convulsion. If both ureters are obstructed, ura?nic syinpioms occur. 

The paroxysm usually terminates suddenly after some minutes or 
hours, the stone escaping into the bladder. 

Diagnosis. Not always easy, but the following are symptoms of 
renal stone ; pain and tenderness in back, persistent hasmaturia, 
albuminuria, hyalin casts, and high specific gravity of urine, and 
attacks of renal colic. The Roentgen ray is the hope for correct 
diagnosis. 

Prognosis. Renal calculus is attended with many dangers. It 
may produce extensive disorganization of the kidneys, or its passage 
along the ureter may prove fatal. If the stone be very large, or if 
more than one, the prognosis is graver. Calculus is a disease very 
apt to recur. Renal sand {gravel) and small concretions may, after 
more or less delay, be voided with the urine. 

Treatment. An attack of renal colic is best relieved by a 
hypodermic injection of morphince sulphas and atropines sulphas, 
and a warm bath or a suppository of ext. opii, gr. j (0.06$ Gm.), ext. 
belladonna; alco., gr. ss (0.032 Gm.), repeated if needed. 

For attacks of gravel, liquor poiassii citratis, f^ss (15 Cc), every 
two hours, and, if much vesical irritability, adding tinctura opii 
camphorata f^ss-j (2-4 Cc). 

For renal hemorrhage, Prof. Bartholow reports success with 

Be . Extracti ergotse fluidi, 

Tincturae krameriae, aaf^ij 60. Cc. M. 

Sig. — One teaspoonful every two or more hours. 

I have always successfully controlled renal hemorrhages with 
twenty-grain (1.3 Gm.) doses of alumen, repeated p. r. n. 

For uric acid calculi, as a solvent, Buffalo Lithia Springs water or 
the Rockbridge Alum Springs water of Virginia, or potassii tartra- 
borates, " obtained by heating together four parts of cream of tartar, 
one part of boracic acid, and ten parts of water. A scruple may be 
given three or four times a day, in water, largely diluted." 

I have met with entire success in four cases of renal calculi by the 
prolonged use of piper -azine gr. v ip.yz Gm.), three times a day in 
several ounces of water, with a non-nitrogenized diet. Potter sug- 



190 PRACTICE OF MEDICINE. 

gests the following in the uric acid diathesis with a tendency to for- 
mation of renal calculi : 

U . Magnesii carbonat., sjj 4. Gm. 

Acid, citrici, ^ij 8. Gm. 

Sodii borat., £ij 8. Gm. 

Aqua? bullientis, Jviij 2 4°- Cc. M. 

SiG. — Tablespoonful three times daily, diluted. 

For phosphatic calculi, as a solvent, ammonii benzoas, well diluted 
and long continued is highly commended. 



CYSTITIS. 

Synonym. Catarrh of the bladder. 

Definition. An inflammation of the mucous membrane lining 
the urinary bladder, acute or chronic in its course, and of either a 
catarrhal, croupous, or diphtheritic character ; characterized by rigors, 
moderate fever, hypogastric pain, frequent but scanty micturition, and 
severe vesical tenesmus, the urine containing pus (pyuria). 

Causes. Acute variety : long retention of urine ; foreign bodies 
in the bladder; pyelitis; urethritis; blows over the pubes ; myelitis, 
and secondary to fevers or diphtheria. Chronic variety : following 
the acute variety ; retention the result of enlarged prostate or a 
urethral stricture ; calculi ; gout ; chronic Bright's disease. 

Pathological Anatomy. In acute catarrhal cystitis there first 
ensues hyperemia of the mucous membrane of the entire or a por- 
tion of the bladder, manifested by redness, swelling, and oedema; 
followed by an increased secretion of the small glands at the base of 
the bladder, and an increased growth and consequent desquamation 
of the vesical epithelium, together with a copious generation of young 
cells ; if the hyperemia be decided, rupture of the capillaries and 
extravasation of blood occur. 

If the inflammation be intense, suppuration of the submucous con- 
nective tissue may result, and ulceration of the mucous membrane 
permit the submucous abscesses to empty into the bladder. 

If the inflammation be of a croupous or diphtheritic character, the 
morbid anatomy does not differ from the same variety of inflamma- 
tions in other mucous membranes. 






DISEASES OF THE KIDNEYS. 191 

In chronic cystitis " the mucous membrane is thick, blue-gray in 
color, and very tough. Muco-pus and viscid mucus are formed in 
large quantities upon its surface. The muscular wall of the bladder 
may sometimes be half an inch thick, and the fasciculi give a ribbed 
appearance to the internal surface, called the ' columnar bladder.' 
The hypertrophy of chronic cystitis may be eccentric or concentric. 
In some cases diverticuli are formed, in whose walls are dilated and 
tortuous veins. In nearly all cases bacteria are found in abundance." 
(Loomis.) 

Symptoms. Acute cystitis : The onset is usually abrupt, by rigors, 
slight fever, loss of appetite, sleeplessness, a feeling of depression, 
frequent micturition, though the urine is only voided drop by drop, 
and its passage followed by distressing vesical tenesmus, the result of 
spasm of the bladder ; pain over the pubis and in the iliac regions, 
of a dull character, at times becoming sharp and agonizing. Burn- 
ing along the urethra adds to the distress of the patient. 

The urine is cloudy, of an alkaline reaction, and at times is fetid, 
the microscope showing epithelium, pus, and red blood corpuscles and 
various forms of bacteria. 

Chronic cystitis : The onset is gradual and insidious, and is excited 
by some obstacle to the evacuation of the urine, such as stricture, 
the presence of a stone in the bladder, or enlargement of the prostate 
gland. There are present dull pain, frequent but scanty micturition. 
The urine is alkaline, containing large amounts of muco-pus or pus ; 
on standing it deposits a thick, glairy, viscid sediment, in which, 
under the microscope, triple phosphates and large pus corpuscles, 
extremely regular both in contents and in shape, may be detected. 

Although the quantity of urine voided by the patient is small, yet 
if immediately after micturition the catheter is used, several ounces 
of fetid, cloudy, alkaline urine may be removed. 

Patients with chronic cystitis usually present decided constitutional 
debility and mental depression. 

Severe local pain, emaciation, and occasional bloody urine indicate 
ulceration of the vesical mucous membrane. 

Diagnosis. Pyelitis has lumbar pains following the course of the 
ureters, frequent micturition without the severe vesical tenesmus ; the 
urine, although cloudy, has an acid or neutral reaction. 

Prognosis. The acute variety is, as a rule, good, being controlled 
by the cause. 



192 PRACTICE OF MEDICINE. 

The chronic variety continues for years, and after hypertrophy of 
the bladder is incurable. 

Treatment. Rest in bed is invaluable. The diet must be restricted, 
all highly-seasoned articles being particularly interdicted ; milk is the 
most suitable article. 

Warm applications over the pubic region are of benefit, and leech- 
ing and cupping over the bladder are of service. 

The urine should be well diluted by large draughts of pure water, 
and particularly the alkaline mineral waters, to wit : Farmville lithia, 
Buffalo lithia, Rockbridge alum, or Vichy waters. The following 
formulas are of decided benefit : 

R . Acidi benzoici, 

Sodiiborat., aa. ^ aa 8. Gm. 

Infusi buchu, vel 

Infusi uvae ursi, f^ v j J 8o. Cc. M. 

SiG. — Tablespoonful every two hours, well diluted. 
Or— 

R. Tinct. hyoscyami, f^ v j 2 4« Cc. 

Tinct. opii camph., f ^ vj 24. Cc. 

Potassii bromidi, 

Sodii bicarb., aa ^viij aa 10.5 Gm. 

Liq. potassii citrat., ... q. s. f^viij q. s. 240. Cc. M. 

Sig. — Tablespoonful every two or three hours, in water. 

A valuable prescription is — 

R. Ext. pichi fid., f^j 30. Cc. 

Potassii nitrat., £j 4. Gm. 

Elix. simplicis, f^fij 9°- Cc. M. 

Sig. — One teaspoonful every two hours, well diluted. 

Or— 

R. Liq. potassae (B. Ph.), f 3 ij 8. Cc. 

01. santal flav., ■. . . fsjij 8. Cc. 

Aq. cinnamom., ad f ^ viij 240. Cc. M. 

Sig. — Tablespoonful three times daily, diluted. (Saundby.) 

For alkaline urine from any cause, ammonii benzoas, gr. xx (1.3 
Gm.) in water, or liquor potassii citratis, seems like a specific. 

For the pain and tenesmus relief is afforded by a suppository of 
extraction opii and exiractum belladonna, repeated as needed. Hot 
compresses over bladder and hot enemata often relieve the pain of 
cystitis. 



DISEASES OF THE KIDNEYS. 193 

The vesical tenes?nus is often benefited by extraction cannabis 
indices fluidum, n^xv-xxx (1-2 Cc), every three or four hours. 

Chronic cystitis. The bladder should be completely emptied with 
the catheter several times in the twenty-four hours. 

The use of eucalyptol, gtt. x-xv (0.6-1 Cc), every four hours, 
well diluted, or a good preparation of tar, or exit -actum grind elice 
fluidum, TT\,xx-f3j (1.3-4 Cc), three or four times daily, or oleum 
sanlali, gtt. v-x (0.3-0.6 Cc), in emulsion or capsule after meals, 
are valuable remedies. Acidum borictun, gr. v-xv (0.3-1 Gm.), 
internally, has removed pus from the urine in chronic cystitis. 
Washing out the bladder with the following mixture is of decided 
benefit : 

R. Sodiiborat., ^j 30. Gm. 

Glycerini, f % ij 60. Cc. 

Aquae, f^ij 60. Cc. 

SiG. — One to two tablespoonfuls added to warm water and injected into the 
bladder once or twice daily. 

The diet should be nutritious and without spices of any kind. The 
free use of the alkaline mineral waters is of value. 



MOVABLE KIDNEY. 

Synonyms. Floating kidney ; wandering kidney ; nephroptosis. 

Definition. A condition of the kidney, either congenital or 
acquired, in which the tissues around about the organ are so lax and 
the renal vessels so elongated as to permit the kidney to be moved in 
certain directions, causing a movable tumor in the abdomen. 

Causes. The kidney is normally held in position by the layer of 
peritoneum which is attached to the anterior surface of its adipose 
capsule. In movable kidney the adipose tissue, in which the normal 
kidney is imbedded, partly or wholly disappears. 

The renal vessels are in many cases abnormally long. Relaxation 
of the abdominal walls from pregnancy or other causes. The use of 
tight corsets or girdles about the waist ; violence ; increased weight 
of the organ from disease ; the pressure of tumors growing in the 
neighborhood of the kidney ; the traction of herniae. 

The condition may be congenital or acquired, more frequently the 
latter. It is far more frequent in women than in men. 
17 



]94 PRACTICE OF MEDICINE. 

Symptoms. Floating kidney may, and often does, exist without 
any noticeable symptoms, the condition being unknown until acci- 
dentally discovered by the physician while making a physical exami- 
nation of the abdomen. 

As a rule, however, patients experience a heavy, dragging pain in 
the abdomen, aggravated when walking or standing. There are 
also present gastro-intestinal symptoms, more or less constant, with 
melancholia, aggravated by the mental anxiety the presence of a 
tu7iior in the abdomen causes the patient, in spite of the assurances 
of the physician that it is not a cancer. 

At times, from some unknown or unrecognized cause, the movable 
kidney swells and becomes very sensitive to the touch, and migrates 
a considerable distance from its normal position. Such an occurrence 
aggravates all the former symptoms mentioned. The condition has 
been ascribed to a twisting of the ureter and consequent retention of 
the urine in the pelvis of the kidney, or to localized peritonitis, or to 
a partial strangulation of the kidney from compression or twisting of 
its blood-vessels. 

Hysterical (?) symptoms are frequently observed in women suffering 
from wandering kidney. 

Diagnosis. The possibility of dislocation of the kidney is to be 
recollected in determining the nature of obscure tumors within the 
abdomen. 

The late Prof. Austin Flint based the recognition of this variety of 
abdominal tumor on the following diagnostic points: "It is situated 
in the hypochondriac region. It has the size and shape of the normal 
kidney, and this may be determinable by palpation, which is most 
advantageously employed by placing one hand over the lumbar region 
and the other in front on the abdominal walls, and then making 
counter-pressure from one hand to the other. It is generally movable, 
and in some cases the organ can be restored to its proper situation." 

Other tumors are to be excluded by the absence of their diagnostic 
characters. 

Prognosis. It is a rare occurrence to have a fatal termination 
from movable kidney per se. 

Treatment. Symptomatic. It is said that some of the incon- 
venience and sometimes suffering attending movable kidney may be 
lessened by means of an abdominal bandage, belt, or supporter. 

If attacks of pain and swelling occur, the patient should be placed 



DISEASES OF THE BLOOD. 195 

in bed, have hot applications over the abdomen, and the use of opiates 
and attempts at replacing the organ. 

Extirpation of a movable kidney has been successfully performed 
a number of times. 

Nephrorrhaphy, an operation for fixation of the kidney by means 
of sutures, has been devised. 



DISEASES OF THE BLOOD. 



ANAEMIA. 

Synonym. Spanaemia. 

Definition. A deficiency of red corpuscles in the blood, or of its 
more important constituents, such as albumin and haemoglobin, or a 
reduction in the amount of blood as a whole ; characterized by pallor 
and general weakness. 

Oligcemia is a general lessened amount of the blood. Isch<z?nia is 
a localized anaemia. 

Causes. Predisposing: Sex; females, pregnancy and meno- 
pause ; heredity ; pronounced anaemia without apparent cause 
is strongly suspicious of concealed tuberculosis. 

Exciting : Deficient food, air, or sunshine ; excessive work ; mental 
worry ; mental shock ; prolonged and frequent nocturnal emissions ; 
excessive nursing ; chronic intestinal catarrh ; Bright's disease ; 
malaria; syphilis; cancer. 

Pathological Anatomy. Post-mortem, the tissues are thin, 
shrunken, and bloodless. If the anaemia has been of long duration, 
patches of fatty change are seen in the various organs. The blood 
has a brighter color, the result of diminution in the number of red 
corpuscles and the quantity of the haemoglobin ; it is thinner than 
normal, and coagulates slowly and imperfectly, from diminution of the 
fibrino-plastic constituent. 

In health the blood of an adult contains about five million red cor- 
puscles to the cubic millimeter (the female adult about half a million 
less). The white cells, in health, average about ten thousand to the 
cubic millimeter. 



196 PRACTICE OF MEDICINE. 

Symptoms. Pallor, gums, tongue, ear, and conjunctivae pale. 
Muscular weakness, inability for exertion. Deficient appetite and 
impaired digestion, attacks of vomiting the result of anaemia of the 
medulla oblongata. Quickened respiration, irritable te?nper, vertigo 
in the erect position, attacks of swooning, hysteria, and rarely epilepsy. 
Irritable heart, with soft systolic basic murmurs. Nocturnal emissions 
in male and deficient menses in female. Marasmus in children. 
More or less general oedema of the eyelids and ankles. Long con- 
tinued, symptoms of fatty changes in various organs or gastric ulcer 
result. 

Diagnosis. The symptoms of anaemia are so characteristic that 
an error is impossible ; the cause of it, however, may be hidden. 

Prognosis. • Favorable if treated early. If protracted, results in 
more or less general symptoms of fatty degenerations or ulcer of the 
stomach. 

Treatment. Remove the cause. Easily assimilated, blood-pro- 
ducing diet. Fresh air, sunlight, and exercise short of fatigue, The 
anaemic patient should spend several hours in bed during the day- 
time. Purgatives, with stomachic tonics, to promote digestion. 

For the anaemia proper, ferru7n in some form is the most valuable 
remedy, always remembering that it is not assimilated if the intestines 
and liver be torpid. Ferri carbonatis, gr. ij-v (0.13-0.32 Gm.), is an 
excellent form of iron too little employed. 

The following alterative tonic, known as Smith's (Dr. A. H.) "four 
chlorides," is frequently of value : 

R. Hydrargyri chloridi corrosivi, . . gr. j-ij .065-13 Gm. 

Liq. arsenici chloridi, f 3 j 4. Cc. 

Tinct. ferri chloridi, 

Acidi hydrochlorici dil. , . . .aafgiv aa 15. Cc. 

Syrupi, f.^iv x 5- Cc. 

Aquoe, adf^vj 180. Cc. M. 

SlG. — One dessertspoonful in a wineglassful of water after each meal. 

Cases of anaemia with weak stomach can take the following "iron 
lemonade" with ease : 

R. Tinct. ferri chloridi, fgij 8. Cc. 

Acid, phosphor, dil., f 3 ij 8. Cc. 

Syr. limonis, f.^ ss l S- Cc. 

Aquce, f^ij 60. Cc. M. 

SlG. — One teaspoonful, well diluted. 



DISEASES OF THE BLOOD. 197 



CHLOROSIS. 



Synonyms. Essential anaemia ; green sickness. 

Definition. A pronounced anaemia met with chiefly in young girls 
about the age of puberty, characterized by diminution in the percent- 
age of haemoglobin. 

Causes. The true cause unknown. A disease for the most part 
of puberty. Most frequently seen in the ill-fed, overworked town 
girls, who are deprived of sunshine and fresh air. Heredity is sup- 
posed to play a part in its causation. Hammond maintains " that it 
is an affection of the nervous system, the blood changes being 
secondary." 

Pathological Anatomy. Death from chlorosis is such a rare 
occurrence that little data is known. The number of red corpuscles 
is nearly normal, but there is marked decrease in the haemoglobin, 
sometimes as low as twenty per cent, of the normal, or even less. 
Virchow pointed out the hypoplasia of the arterial system, many 
arteries being congenitally small. The body is usually well nour- 
ished and the subcutaneous fat well distributed. There is pallor of 
the organs and muscular system. The spleen, lymphatics, and the 
marrow of the bones are not affected. 

Symptoms. The condition is associated with disorders of men- 
struation. The young girl experiences a change of disposition, becom- 
ing morose and despondent, rarely hysterical or melancholiac. 

" As respects the actual condition of the sexual organs, there are 
two forms of derangement which happen in chlorosis : there are the 
amenorrhaeic form and the menorrhagic form." 

After an attack of menorrhagia or after the failure of the flow to 
appear, the changes occur. The complexion changes, blondes be- 
coming pallid, waxy, and puffy without oedema ; brunettes becoming 
muddy and grayish in color, with bluish black rings under the eyes. 
Weariness and fatigue upon the least exertion ; the heart irritable, 
with shortness of breath, pulse full but soft, and at times pulsations in 
the peripheral veins. The appetite is vitiated, the digestion imper- 
fect ; and attacks of gastralgia are frequent. 

A not infrequent complication is gastric ulcer. Phthisis develops 
in those having the slightest predisposition. 

Examination of the blood shows a relative decrease in quality and 



198 PRACTICE OF MEDICINE. 

quantity of the haemoglobin, resulting in the blood being paler than 
normal. The red corpuscles are also lighter in color and show less 
tendency to form rouleaux ; their character also changes, not all 
being of uniform size, some normal, others small (microcytes), others 
unusually large (macrocytes), others irregularly shaped (poikilocytes). 
The number may be normal, 5,000,000 to the cubic millimeter, or the 
number is occasionally increased, but it is usually lessened, there 
being as few as 3,000,000 or 2,000,000. 

The white corpuscles are usually normal in number, but in some 
instances their number is increased (leucocytosis). Rarely granular 
bodies are found in the blood which are generally regarded as the 
products of the degeneration of the white blood corpuscles. 

Diagnosis. The disease is usually recognized at once by the 
color of the patient, whence its common name, green sickness. 

The circulatory symptoms and slight oedema may be mistaken for 
cardiac or nephritic diseases. 

Prognosis. The liability to complications and also to relapses, 
and the lack of knowledge of the true cause, make the prognosis 
always uncertain, 

Treatment. Three indications to be met in the treatment of 
chlorosis : plenty of food, fresh air, and ferrum. The form of iron is 
immaterial. The tinctura ferri chloridt is the preparation usually 
prescribed. 

J. W. England, Ph.G., has proposed the following formula for an 
iron pill that has been successfully used at the Philadelphia Hospital: 

R . Massae ferri carb 
Potassii sulph., 
Potassii carb., 
Pulv. altheae, . 

Pulv. acacioe, q. s. q. s. M. 

Ft. pil. No. xvj, and inclose in gelatin capsules. 

The following is Blaud's formula, so highly lauded by Nie- 
meyer : 

U . Pulv. ferri sulph., 

Potassii carbonat. purae, . . aafjss aa 15. Gm. 

Tragacanthoe, q. s. M. 

Ft. pil. No. xcvj. 

SlG. — One to three or four pills three times daily. 



gr. xlviij 
gr. xxxiv 


3. Gm. 

2. Gm. 


gr. iss 


.33 Gm. 
.02 Gm. 


q. s. 


q. s. 



DISEASES OF THE BLOOD. 199 

In some instances ferrum alone does not seem to answer ; in such 
cases the addition of arsenicum is valuable ; a good combination is — 

H. Ferri arseniatis, gr. ^-\ .005-.OH Gm. 

Ext. nucis vomicae, gr. \-\ .011-016 Gm. M. 

Ft. pil. No. j. 
Sig. — After meals. 

ir — 

R . Liq. arsenici chloridi, f^ij 8. Cc. 

Tinct. ferri chloridi, . . . . . . f^vij 28. Cc. 

Glycerini, f^j 30. Cc. 

Elix. aurantii, . . . . q. s. adf^iij 90. Cc. M. 
Sig. — One teaspoonful after meals, in water. 



PROGRESSIVE PERNICIOUS ANAEMIA. 

Synonyms. Idiopathic anaemia ; anaematosis ; essential anaemia ; 
anaemia of fatty heart. 

Definition. A pernicious, progressive form of anaemia, of un- 
known cause, usually resisting all treatment, and toward its termina- 
tion associated with fever. 

Causes. The underlying cause of idiopathic anaemia is not 
known. Among the exciting causes may be mentioned pregnancy, 
syphilis, and great worry. It is thought that it is probably the result 
of a toxin. 

Pathological Anatomy. The blood is scanty and pale, with 
diminished red corpuscles and haemoglobin, showing a very feeble 
tendency to coagulate. There is no increase in the white corpuscles. 

The marrow in adult bones becomes fcetal, red, and adenoid, and 
;ontains microcytes ; several other changes have occurred second- 
arily in the marrow. 

Secondary to the anaemia, the heart, larger arteries, and certain 
capillary tracts exhibit circumscribed or diffused fatty degeneration. 

The liver, spleen, kidneys, and stomach are decidedly anaemic, 
causing fatty changes in those organs. The skin may contain 
petechiae of a purplish or brownish tint, and internal hemorrhages 
are not infrequent; retinal hemorrhage is rarely wanting. 

There is not much emaciation, though the pallor is pronounced. 



200 PRACTICE OF MEDICINE. 

Symptoms. It begins insidiously with increasing languor and 
pallor, the muscular weakness compelling the patient to take his bed. 
Cardiac palpitation, dyspnoea, attacks of syncope, oedema, and swell- 
ing about the ankles, petechial spots scattered irregularly over the 
surface ; tenderness over the sternum and other superficial bones is a 
frequent symptom. 

The appetite is wanting, and nausea and vomiting occur, associated 
with marked dyspepsia and persistent diarrhoea. As the disease 
progresses a remittent form of fever develops, the temperature fre- 
quently showing io2°-io4° F. 

Disorders of vision are the result of the retinal hemorrhage. The 
cardiac sounds are feeble, and associated with soft basic or anaemic 
murmurs. 

The blood shows under the microscope the changes described in 
chlorosis, save the red corpuscles may be reduced to as few as 500,- 
000, or even less, to the cubic millimetre. 

" In addition, the following points of great diagnostic importance 
are to be noted. 

" First, the individual red corpuscles are richer than normal in 
haemoglobin. 

" Second, many red corpuscles are larger than normal (megalo- 
cytes). 

" Third, the red corpuscles are deformed, some being ovoid, others 
irregular in shape from projections and constrictions on their surfaces 
(poikilocytes). 

" Fourth, there are present microcytes or red blood-cells, which 
are smaller than normal. 

" Fifth, nucleated red blood-cells (normoblasts). 

" Sixth, quite constantly, there are other large cells like the megalo- 
cytes, named megaloblasts, which have a pale staining nucleus." 
(Hare.) 

Diagnosis. Progressive pernicious anaemia is distinguished from 
simple anaemia and chlorosis by the greater severity of the former. 
From leucocythemia by the normal-sized spleen and liver, and the 
absence of (leucocytosis) increase in the white corpuscles. 

Prognosis. Unfavorable as a rule, although recoveries occur, but 
relapses frequent. 

Treatment. The employment of arsenicum, either alone or com- 
bined with ferrum, has considerably changed the prognosis of per- 



DISEASES OF THE BLOOD. 201 

nicious anaemia. The arsenicum must be pushed to the extreme point 
of toleration and continued for a long time. 
Rest in bed and a liberal nutritious diet are also essential. 



LEUCOCYTHEMIA. 

Synonyms. Leucaemia ; white cell blood ; white blood ; anaemia 
splenica. 

Definition. A condition in which there is an enormous increase 
in the number of white blood corpuscles, with enlargement of the 
lymphatic glands, spleen, and often of the bone marrow — viz. : 
splenic, lymphatic, or myelogenic, and is characterized by symptoms 
of pronounced anaemia. 

Causes. The real cause and nature of the affection is unknown. 

Pathological Anatomy. The spleen is increased in size, den- 
sity, and firmness ; the lymphatic glands all over the body also 
enlarge, but are soft to the touch, often fluctuating ; the marrow of the 
bones changes from its normal rose color to that of a greenish-yellow ; 
the liver also enlarges enormously. The blood is paler than normal, 
its specific gravity reduced from 1.055 to 1.040 or lower, and the white 
corpuscles increased (leucocytosis) in number and in size, the red 
corpuscles being lessened in number and size. 

Symptoms. The onset is insidious, and the early progress of the 
disease is identical with that of simple anaemia, accompanied by 
swelling of the abdomen and a feeling of fullness and pain in the 
splenic region, due to the enlargement of that organ. 

In the lymphatic variety, enlargement of the glands in the groin, 
neck, and axillary region are associated with Wit great pallor. 

In the myelogenic variety, the bones, more particularly the ribs 
and sternum, are tender on pressure, the patient developing a waxy 
appearance. 

In each variety the appetite is poor, the digestion feeble, the bowels 
loose, the patient easily fatigued, with cardiac palpitation and dysp- 
noea, with oedema of the eyelids and ankles. The urine is scanty 
and of high specific gravity — 1. 020-1. 030. Fatal hemorrhages occur 
near the termination of the disease. 

The blood is pale and watery. The white blood corpuscles are 
enormously increased in number. The average number of white 
18 



202 PRACTICE OF MEDICINE. 

corpuscles to the cubic millimetre normally is about 10,000. Cases 
are recorded in which the number of white blood corpuscles has 
equaled or even exceeded the red blood corpuscles. The size of the 
white corpuscles varies in different cases and also in the same case. 

Diagnosis. This should cause but little trouble if enlarged 
spleen, lymphatic glands, and tender bones are associated with great 
pallor, and the characteristic appearance of the blood as demonstrated 
by a "puncture of the finger of the patient, and receiving the blood 
on a piece of white linen or a lawn handkerchief, and placing by the 
side of it a similar stain of blood from a healthy subject. The full 
color of the latter contrasts strikingly with the stain of the former, 
which is hardly of a blood color and translucent." 

A microscopical examination and blood count at once determines 
the presence of the disease. 

Acute phthisis associated with enlarged bronchial and cervical 
glands shows the leucocytosis of leucocythemia, but has the lung 
changes and hectic symptoms in addition. 

Prognosis. Unfavorable. The average duration is between two 
and three years. Cases of what are termed "acute leukaemia," 
proving fatal in a few months, occur. 

Treatment. Symptomatic. A combination of the following 
remedies, with generous diet, fresh air, sunshine, pleasant surround- 
ings, oleujn morrhucp, and the hypophosphites, have at times seemed 
of temporary value — to wit : quinines sulphas, arsenicum, ferrum, and 
ergota. 

Dr. Da Costa has had some success by the inhalation of oxygen, 
twenty to one hundred liters during the day. 

HODGKIN'S DISEASE. 

Synonyms. Pseudo-leukemia ; Pseudo-leucocythemia ; lym- 
phatic anaemia ; lymphadenoma. 

Definition. An affection characterized by hypertrophy of the 
lymphatic glands in various parts of the body, associated with marked 
anaemia. 

Cause. Unknown. 

Pathological Anatomy. A hyperplasia of the lymph glands 
interfering more or less with their functions. The enlargement may 
be confined to one isolated gland, or a number may be affected in 



DISEASES OF THE BLOOD. 203 

different portions of the body, or a number in one location may be 
simultaneously affected, causing a tumor varying in size from an egg 
to an orange or even larger. 

The spleen and liver are involved in two-thirds of the cases. 
"The marrow of the long bones may be converted into a rich 
lymphoid tissue." (Osier.) 

The red blood corpuscles are decreased in number and altered in 
size and shape ; the white blood corpuscles are often increased in 
number. 

Symptoms. A slowly developing anaemia with isolated or dif- 
fused enlargement of the lymphatic glands. As the condition 
develops, fever of a remittent character occurs, with feeble cardiac 
action and shortness of breath. Hemorrhages may occur. The 
patient grows progressively worse with all the associated symptoms of 
deficient blood, death occurring by asthenia. 

Diagnosis. A study of the clinical history will prevent error, as 
tubercular or scrofulous glands a,re accompanied with tubercular 
changes in the lungs, and do not present the same blood-changes as 
Hodgkin's disease. 

Prognosis. Unfavorable. The progress may be slow, but it is 
none the less toward a fatal termination. 

Treatment. The indications are all toward a building up of the 
blood. Amongst the remedies recommended are arsenicum, phos- 
phorus, ferrum, quinincz sulphas, and oleum morrhua. Excision of 
the glands in the early stage may be practiced. 

ADDISON'S DISEASE. 

Synonym. Melasma supra-renalis. 

Definition. " The bronzed-skin disease." Thus defined by 
Averbeck : "A well-marked constitutional disease, exhibiting itself 
locally as a chronic inflammation of the supra-renal capsules, but in 
its essence consisting in a peculiar anaemic condition, always tending 
toward death, which is characterized by intense development of pig- 
ment in the cells of the rete malpighii and in the epithelium of the 
mucous membrane of the mouth." 

Causes. Obscure. Tubercle, scrofula, and syphilis have each 
been given as the cause. 

Pathological Anatomy. A low form of inflammation, termi- 



204 PRACTICE OF MEDICINE. 

nating in degeneration of the supra-renal capsule. The blood is 
deficient in fibrin and red corpuscles, with a slight increase of the 
white corpuscles. Fatty degeneration of the heart and vessels has 
been observed in some cases. 

" The most striking change during life — the abnormal pigmentation 
— is due to the deposition of granular pigment in the cells of the rete 
malpighii, in the papillary portion of the cutis, and even in the con- 
nective-tissue corpuscles. No change occurs in the proper structure 
of the skin. Similar pigment deposits occur in the mucous membrane 
of the mouth, especially along the edges of the teeth." 

" The disease of the supra-renal capsules excites an irritation of 
the vaso-motor system — the trophic system — which leads to the pig- 
mentation." 

Symptoms. The onset of the disease is insidious, with a feeling 
of extreme languor, muscular fatigue ; asthenia, indigestion, anorexia, 
dyspnoea, cardiac paipitatio?t, vertigo, melancholia, and excessive 
drowsiness. 

The surface is first pale, then changes to a hue like that of melan- 
cemia, changing to icteroid, finally resembling the color of a mulatto, 
and then to a lustreless bronze. These changes also occur on the 
mucous membrane of the lips, tongue, gums, and mouth. 

Prognosis. An incurable disease. Duration, a year or two. 

Treatment. Symptomatic. 



HAEMOPHILIA. 

Synonyms. Hemorrhagic diathesis ; " bleeder's disease." 

Definition. A congenital condition characterized by a tendency 
to uncontrollable hemorrhages, with or without abrasions. 

Cause. Hereditary. 

Symptoms. The bleeding appears about the period of first 
dentition, and consists of spontaneous hemorrhages from the mucous 
membrane of the nose, mouth, lungs, stomach, intestines, and genito- 
urinary passages, or in perfect cases hemorrhages occur directly from 
the fingers, toes, lobes of the ears, back of the hands or arms, without 
any apparent change in the skin, and continue in spite of the most 
powerful means, for days or weeks. Traumatic hemorrhages occur 
if an injury of any kind is sustained about the period of the develop- 
ment of the bleeding. 



DISEASES OF THE BLOOD. 205 

Epistaxis is the most common form of all those named. 

Attacks of arthritis with fever occur with haemophilia, resembling 
acute rheumatism. 

As a result of the great loss of blood, the individual suffers from all 
the symptoms of profound anaemia. 

Diagnosis. It is impossible to confound the "bleeder's disease" 
with any other affection. 

Prognosis. Death is the usual termination within a few weeks 
from the time of its development, which may not be until adult life. 

Treatment. Entirely symptomatic. It is claimed that " ftotassii 
chloras — an ounce of a saturated solution three times a day — com- 
bined with tinctura ferri chloridi" will eradicate the constitutional 
tendency. 

SCORBUTUS. 

Synonyms. Scurvy ; scorbutic purpura. 

Definition. A peculiar condition of malnutrition or anaemia, 
gradually developing upon a dietary deficient in fresh vegetable 
material ; characterized by decided anaemia, debility, mental lethargy, 
petechiae, and a swollen and spongy state of the gums, with a ten- 
dency to bleed upon the slightest irritation. 

Causes. The disease only occurs when fresh vegetable nutriment 
or some appropriate substitute has been for a time partially or com- 
pletely withheld. It is held that the diet alone is not sufficient to 
cause the disease ; the mental factor of depression of spirits, or in 
some cases home-sickness (nostalgia), must be associated. 

It is sometimes classed as an infectious disease, due to a peculiar 
germ, a view which is gaining ground. 

Pathological Anatomy. An undetermined derangement in 
the composition of the blood, with diminished proportion of the pot- 
ash salts. Spleen enlarged. The tissues are wasted and present 
extravasations, due to either one of or the combined presence of the 
following conditions, to wit : liquid condition of the blood, allowing 
it to escape from the vessels, alterations in the walls of the vessels, or 
a vasomotor paralysis. 

Symptoms. General weakness, lassitude, indisposition to either 
mental or physical exertion. The skin is dry, rough, and of a muddy 
pallor, the face pale and bloated. Swelling and sponginess of the 



206 PRACTICE OF MEDICINE. 

gums, with great tendency to bleed and an exceedingly offensive 
breath. Looseness of the teeth, hemorrhages from mucous surfaces, 
and extravasations of blood within and beneath the skin. The lips 
are pale, which is in striking contrast to the redness of the gums ; 
the eyes are sunken and surrounded by dark blue circles. 

Hemorrhages occur from the stomach, mouth, bronchial tubes, 
intestinal canal, and vagina. The skin is dry and rough, resembling 
that of a plucked fowl. (Edema of the face and ankles not infrequent. 

Depression of the spirits is characteristic. Palpitation and dyspnoea 
on exertion. Urine high-colored, speedily becoming fetid. 

The patient usually longs for fresh vegetables and fruits. 

Complications. Dysentery. Scorbutic dysentery is a frequent 
complication. It may co-exist with typhoid and typhus fever. 

Prognosis. Favorable, if early and properly treated. 

Treatment. The chief indication is the assimilation of the ali- 
mentary principles needed for the healthy constitution of the blood 
and the invigoration of the system. 

The juice of lemons, oranges, and other fruits; it is wonderful what 
improvement will follow the use of two or three lemons daily. Anti- 
scorbutic vegetables, to wit : raw cabbage, cresses, and raw potatoes, 
sauer kraut, in conjunction with meats, milk, and farinaceous food. 

Improve the appetite and digestion by the use of strychnines sulphas, 
quinines sulphas, mineral acids, and bitter infusions. Potassii c Moras, 
locally, will relieve the oral symptoms. 



PURPURA. 

Synonyms. Haemorrhcea petechialis ; Morbus maculosus Werl- 
hofii. 

Definition. An acute disease, characterized by purplish discol- 
orations of the skin, the result of hemorrhages into the upper layers 
of the cutis and beneath the epidermis. When the purpuric spots are 
tiny, like a pin-point, they are termed petechias ; when larger in size, 
they are termed ecchymoses. 

Varieties. Purpura simplex ; purpura hemorrhagica ; purpura 
urticans ; peliosis rheumatica. 

Causes. Not properly understood ; a special germ supposed to be 
the cause. It may occur at any age, but is especially frequent in 



DISEASES OF THE BLOOD. 207 

children and elderly people. Its occurrence after the ingestion of 
certain articles of diet has been observed. 

Symptoms. Purpura simplex is the mildest form of the affection , 
and is characterized by the sudden appearance of small, bright red 
spots — a cutaneous hemorrhage — most commonly on the legs coming 
in crops, associated with slight lassitude, mild febrile reaction, and 
aching pains in the limbs. The hue of the spots rapidly fades to a 
purplish color and slowly disappear. Relapses are common. 

Purpura hczinorrhagica has, in addition to the eruption of purpura 
simplex, — the cutaneous hemorrhage, — a flow of blood from the free 
surface of mucous membranes. The most common hemorrhage is 
epistaxis, slight or profuse. Other hemorrhages are hcematemesis, 
melcpna, hematuria, hemoptysis, menorrhagia, and also into the sub- 
stance of the mucous membranes of the palate, cheek, and gums. 
This variety is associated with great debility and depression, moderate 
fever, and disorders of digestion. Marked ancemia results from the 
hemorrhages. 

Purpura urticans is a combination of urticaria and purpura sim- 
p/ex. It is characterized by rounded and reddish elevations of the 
cuticle, resembling wheals, but which are not accompanied, like the 
wheals of urticaria, by any sensation of itching or tingling. They 
are usually situated on the legs, thighs, breast, and arms, and are inter- 
spersed with petechiae. They gradually form and subside within 
twenty-four or thirty-six hours. Relapses are frequent. 

This variety is also associated with malaise, moderate fever, and 
pains in the limbs. 

Peliosis rhewnaiica (Schonlein's disease) is characterized by mul- 
tiple arthritis and a purpuric eruption ; frequently the arthritic symp- 
toms are associated with urticaria or with erythema exudativum. 
(Edema is often marked, as in the fever, sore-throat, and general con- 
stitutional symptoms. The eruption is sometimes of vesicles — pem- 
phigoid purpura . 

Diagnosis. The purpuric eruption in each variety of the affection 
is so characteristic that an error seems impossible. 

Prognosis. Purpura simplex and purpura urticans are favorable, 
but relapses are very frequent. Purpura hemorrhagica is always a 
grave disease, often proving fatal from exhaustion, or, more rarely, 
from cerebral or pulmonary hemorrhage. Peliosis rheumatica is often 
a severe affection, but recovery is the rule. 



208 PRACTICE OF MEDICINE. 

Treatment. Rest and a concentrated nutritious diet, and the 
moderate use of stimulants and tonics. Arsenicum in large doses is 
often valuable, using liquor potassii arsenitis, to combat the resulting 
anaemia. 

The internal use of oleum terebinthina is one of the most reliable 
remedies for many forms of the disease, but not when hemorrhages 
occur from the stomach or kidneys. The following is an eligible 
formula : 

R. 01. terebinthinse, f.^ij 8. Cc. 

01. amygdalae express., f Jj 30. Cc. 

Tinct. opii deodcrat. , f^ss 2. Cc. 

Mucil. acaciae, f]fj 30. Cc. 

Aq. lauro-cerasi, adfjiij ad 90. Cc. M. 

SiG. — One tablespoonful every three or four hours, diluted. 

Among the other numerous remedies suggested, the most reliable 
have been acidum sulphuricum dilutum and tinctura ferri chloridi. 
Good results have followed acidum carbolicum, ff\, ij-iij (0.13-0.2 Cc.) 
every three hours, in cases seen by the author, and a particularly 
persistent case was cured by full doses of potassii iodidum. Dr. 
Da Costa, for hemorrhages, strongly recommends extractum ergotae 
fluidum, fgss-f^j (2-4 Cc.) every two hours ; or acidum sulphuricum 
dilutum, l^x-xx (0.6-1.3 Cc) every few hours. 

" If hemorrhages that are threatened come on, with a strong pulse, 
flushed face, headache, and excitement, digitalis, guinina, and ergota 
are the appropriate medicaments." (Bartholow.) 

Argenti nitras, gr. ^-]i (0.005-0.016 Gm.), three or four times 
daily, is of value in purpura haemorrhagica. Argentum is said to have 
a specific influence on the capillary circulation by its impression on 
the vasomotor nerves. 

Locally, to arrest bleeding, astringents and either hot or cold water 
or ice. 



ACUTE GENERAL DISEASES. 209 

ACUTE GENERAL DISEASES. 

I 
PAROTIDITIS. 

Synonyms. — Parotitis ; mumps. 

Definition. An acute, specific, infectious inflammation of one or 
both parotid and other salivary glands and the surrounding connec- 
tive tissue, with a very strong tendency to migrate into the mammae 
or testes ; characterized by pain, swelling, and disordered function of 
the glands. 

Causes. A specific poison. Contagious. Occurs in epidemics, 
although isolated cases are seen. Males more liable than females. 
The most common ages between five years and puberty. As a rule, 
it occurs but once in the same individual. 

The period of incubation is from two to three weeks. 

Pathological Anatomy. There is inflammation of one or both 
parotid glands, and in severe epidemics the cellular tissue pervading 
the gland is involved. 

The catarrhal inflammation begins in the gland ducts and rapidly 
extends to the gland proper. There is congestion, swelling, and an 
infiltration of serous fluid, with more or less infiltration of the adja- 
cent tissues. The swelling may suddenly reach an enormous size 
and as suddenly decline, the gland returning to its normal condition, 
or, rarely, an abscess results, with partial or complete destruction of 
the gland. Occasionally the submaxillary gland is involved, also the 
mammae and testes. 

Metastatic parotiditis occurs secondary to severe blood-poisoning, 
as in pyaemia, typhoid or typhus fevers, or diphtheria. The usual 
termination of secondary parotiditis is by suppuration and destruction 
of gland structure. 

Symptoms. The onset is rather sudden, by malaise, chill, fever, 
ioi°-io3° F., quick pulse, headache, dry skin, scanty urine, followed 
within a day or two by stiffness at the angles of the jaw, swelling of 
the parotid and other salivary glands, pain increased by moving the 
jaws, with getieral oedema of the effected side of the face, at times the 



210 PRACTICE OF MEDICINE. 

skin being reddened. Salivation is frequent, and occasionally deaf- 
ness occurs. 

The swelling and other glandular symptoms subside about the 
sixth or seventh day, to be followed by restoration to health, or, what 
is more common, the involvement of the opposite gland. 

At any time during the disease metastasis to the mammce, ovaries, 
or testes \s apt to occur, when the symptoms peculiar to such affections 
will be added. It has been noted that a continuance of the tempera- 
ture after the decline of the parotid symptoms has begun usually is 
significant of metastasis. It is claimed that the involvement of other 
organs during the course of mumps is not an example of metastasis, 
but is a true transfer of the disease. 

Diagnosis. An error seems impossible. 

Prognosis. Simple mumps, favorable; the chief danger being 
from the altered function of the mammae, ovary, or testes after 
metastasis. 

Treatment. The disease being self-limited, the indications are 
entirely symptomatic, with attention to the secretions, although ex- 
tractum pilocarpi fluidwn, Ti\,x-xxx (0.6-2 Cc), repeated, has been 
used with varying success as a specific. 

Locally, either cold or warmth to the affected gland, whichever is 
most agreeable, or equal parts oiunguenium belladonnce et hydrargyri. 

If the swelling shows a tendency to linger, use small blisters over 
the part and administer potassii iodidum ; if suppuration occur, 
evacuate pus, apply poultices, and administer quinines sulphas. 

If orchitis occur, the use of the belladonna and mercurial ointment 
or the ice bag to the inflamed testicle, and the internal use of tinctura 
pulsatillce, n\,iij-v (0.2-0.3 Cc.) every hour or two, ox potassii iodidum. 

DIPHTHERIA. 

Synonyms. Putrid sore throat ; malignant ulcerous sore throat; 
malignant quinsy; membranous angina. 

Definition. An acute, specific, constitutional disease; both epi- 
demic and contagious, beginning by an affection of the throat, char- 
acterized by a local exudation and glandular enlargements ; attended 
with fever, great prostration of the vital powers, and albuminuria, and 
often having for its sequelae various paralyses. 



ACUTE GENERAL DISEASES. 211 



I_ „„._._ „ 
in its growth produces a potent toxic substance, — a toxalbumin, — the 
absorption of which produces the disease, and not the organism itself. 
The diphtheria bacillus is associated with other pathogenic bacteria, 
the most active of which is the streptococcus pyogenes. It is pre- 
eminently a disease of childhood. It is apt to recur in those who 
have once been affected. All conditions of bad hygiene increase 
its virulence and diffusion, although the chief cause of its spread is 
contagion. Nasal, pharyngeal, and laryngeal catarrh are the kind 
of soil promoting the growth of the bacillus and its toxin. 

The poison exists in the exudation and secretions of the fauces and 
saliva, and floats in the atmosphere at a considerable distance from 
the patient. The virus adheres to the clothing, the bedding, the fur- 
niture, and the room which the patient occupied. 
The period of incubation is from three to five days. 
Pathological Anatomy. The diphtheritic inflammation differs 
from either the croupous or catarrhal form, in that the exudation 
is not only upon, but also within, the substance of the mucous mem- 
brane. 

At first there is redness, which may begin in any part of the throat, 
associated with swelling and an increased secretion of viscus mucus. 
The redness spreads over the entire mucous surface, when the exuda- 
tion makes its appearance, at first giving the affected mucous mem- 
brane a glazed appearance, which is very characteristic. The deposit 
may commence from one or several points, such as one tonsil, the 
soft palate, or the back of the fauces, which, however, speedily extend 
and coalesce, forming extensive patches, or cover uniformly the entire 
surface. 

The patches are of variable thickness, which is increased by suc- 
cessive layers being formed underneath. 

The color is usually gray, white, or slightly yellow, but may be 
brownish or blackish, the consistence ranging from " cream to wash 
leather." 

On removing the membrane, which is accomplished with more or 
less difficulty, a raw bleeding surface is exposed, and at times an 
ulcer, which is speedily covered with a fresh deposit. 

If the exudation separate itself, it is either not renewed at all or 
only in thinner films. 
The exudation or membrane, examined by the microscope, is 



212 PRACTICE OF MEDICINE. 

composed of fibrin, pus corpuscles, epithelial granular cells, and the 
Klebs-LoefHer bacillus and other pathogenic bacteria. 

If the larynx ; trachea, or nasal mucous membranes participate in 
the disease, the croupous and not the diphtheritic form of inflamma- 
tion occurs. 

The lymphatic glands of the neck, whose vessels originate in the 
faucial tissues, are enlarged and inflamed, and contain large numbers 
of bacteria, probably originating as the result of decomposition. 

The muscular tissue of the heart becomes soft, is easily torn, and 
its fibrillae are far advanced in granular degeneration. Ulcerative 
endocarditis has been frequently observed. The kidneys undergo a 
granular degeneration in severe attacks. The blood undergoes altera- 
tion, being black and fluid. 

Symptoms. Following the law of contagious diseases, the symp- 
toms vary in intensity in different cases, the prominent symptoms 
being often disproportionate to the gravity of the attack. 

The invasion may be mild, with rigors succeeded by moderate 
fever, headache, languor, loss of appetite, stiffness of the neck, tender- 
ness about the angles of the jaw, or slight soreness of the throat. 

In other cases the invasion is more abrupt and severe, with chilli- 
ness followed by great febrile reaction, 103 to 105 F., pain in the ear, 
aching of the limbs, loss of strength, painful deglutition, and swelling 
of the neck, compelling the patient to take to bed from the onset. 

The appetite is poor, the tongue slightly coated, sometimes more 
or less exudation appearing upon it, the bowels either regular or 
slightly relaxed. The pulse, at first full and strong, soon becomes 
either rapid or slow, but compressible. The urine is scanty, high- 
colored, and contains albumin. 

The local symptoms in the majority of cases are associated with 
the throat. The patient often complains of a frequent and persistent 
desire to hawk, in order to clear the throat. On i?ispection, the fauces 
are seen red and swollen and more or less covered with a film of 
diphtheritic exudation, giving a glazed appearance, soon followed by 
the dirty-white membrane ; sometimes the tonsils and uvula are 
greatly swollen and spotted with exudation. In severe cases, more 
or less ulceration or sloughing may be observed. Not infrequently 
fragments of exudation, the false membrane, are expectorated, with 
particles of the ulcerated tissues, having an offensive odor, which is 
transmitted to the breath. The lymphatic glands of the neck are 



ACUTE GENERAL DISEASES. 213 

enlarged and tender, and in severe cases the tissues of the neck are 
greatly tumefied. 

Extension to the nasal cavities causes a sanious and offensive 
discharge from the nose, with attacks of epistaxis. 

Extension to the larynx is indicated by hoarseness or complete loss 
of voice, croupy cough, and obstructive dyspnoea, which often becomes 
urgent, the breathing being noisy and stridulous, and subject to par- 
oxysmal exacerbations. If the inflammation extend to the bronchi, 
the breathing becomes still more embarrassed. 

Duration. Ranges from two to fourteen days, an average being 
about nine days, although complications and sequelae may prolong its 
course. 

Relapses are not uncommon. 

Sequelae. Those who recover from a severe attack remain often 
for weeks with a pale and cachectic appearance, due to the profound 
blood alteration. 

Paralysis is a common sequela, following the mild as often as the 
severe attacks. Usually not occurring until the patient seems fully 
convalescent. 

Pharyngeal paralysis is most common, causing difficulty or inability 
of deglutition, fluids regurgitating through the nose. 

Cardiac paralysis, bradycardia, is not infrequent, the pulsations 
descending to 60, 50, 40, and, in a case seen by the author, to 20 per 
minute. Heart failure and fatal syncope may occur at any time 
during the disease. 

Diphtheritic paralysis may affect the motor muscles of the eye, 
causing strabismus ; the muscles of one side, hemiplegia ; of the legs, 
paraplegia ; and of the bladder, leading to reteiition of urine or 
difficulty in voiding it. 

Multiple neuritis, with the attending loss of power, is a rare sequela. 

Sensation and the reflexes are diminished 'in the paralyzed parts. 

Diagnosis. The diagnosis is now made certain by making a 
culture from the deposit, and if the bacillus is present, the charac- 
teristic colonies can be seen in the course of twenty-four hours, under 
the microscope. 

From follicular ulceration of the tonsils, which is frequently termed 
diphtheria, by the slight or absent systemic symptoms, the ulcerated 
condition being limited to the tonsils, but often one, and the absence 
of glandular enlargement, and following palsies. 



214 PRACTICE OF MEDJCINE. 

From pharyngitis , by the absence of exudation and loss of faucial 
tissue and constitutional symptoms. 

From scarlatina, by the presence of the eruption and the absence 
of membrane in the fauces. The association of scarlatina and diph- 
theria must not be forgotten. 

From membranous croup, by the difference in the constitutional 
symptoms ; croup appears sporadically and is not contagious, diph- 
theria being highly contagious and frequently occurs in epidemics; 
in diphtheria of the larynx the depression is clearly that of blood- 
poisoning, while in croup the depression is in proportion to the 
mechanical obstruction of the respiration by the membranous exuda- 
tion. The pathology of croup is simple and easy of investigation; 
diphtheria is obscure in its etiology and progress. The temperature 
record of croup is a high one until carbonic acid poisoning is immi- 
nent from the mechanical obstruction to respiration, while in diph- 
theria the tendency to a decline in the temperature after the fourth 
day is nearly characteristic, regardless of the amount of laryngeal 
obstruction. In croup the pharynx contains no membrane, and is 
but slightly, if at all, inflamed, and associated trouble in the nose is 
of the rarest occurrence, the very reverse obtaining in diphtheria. In 
croup the laryngeal symptoms are from the onset, while in laryngeal 
diphtheria the pharyngeal symptoms almost always precede. In 
croup glandular involvement is a clinical novelty, as are subsequent 
palsies, while glandular involvement and various palsies are the rule 
in diphtheria. Albuminuria is the rule in diphtheria, seldom occur- 
ring in croup. 

Prognosis. Always grave, but more so in children than in 
adults. Its gravity, in the majority of cases, is proportionate to the 
local symptoms. The average mortality is about ten per cent. 

Favorable indications are, moderate fever, strength slightly im- 
paired, a good constitution, and moderate exudation. 

Unfavorable indications are, high fever, great depression, spreading 
exudation, great swelling of the cervical glands, large amounts of 
albumin, extension to larynx and nasal mucous membranes, hemor- 
rhages from the fauces and nose, and an epidemic character. 

Treatment. The introduction of the antitoxin serum has changed 
the prognosis of this formidable malady. The injections are made 
where the skin is loose and at points that will not interfere with the 
comfort of the patient. The dose must be estimated in antitoxic 



ACUTE GENERAL DISEASES. 215 

units, and not by the unit of the serum. The dose is from iooo to 
3000 units, according to the severity of the attack. If the dose is 
sufficient, evidences of improvement are seen within a few hours. 
With the serum-therapy must be associated the constitutional treat- 
ment, as it is a disease of great debility, and the blood being more or 
less altered, it follows that sustaining measures should be resorted to 
in all cases. 

The diet should be of the most nutritious character, from the onset, 
using such articles as milk, eggs, broths, and oysters, at intervals of 
every two or three hours. If deglutition be too painful, resort must be 
had to nutritious enemata, the following being a suitable formula : 

R. Milk, fgj 30. Cc. 

Spts. frumenti, f^iv r 5- Cc. 

Egg, One M. 

Sig. — Little salt added, beaten up and warmed. 

Stimulants should be used boldly from the onset, guiding the dose 
by the effect ; usually a child of two years requires from thirty to sixty 
minims (2-4 Cc.) of spiritus vini gallici or spiriius frumenti every 
two or three hours; an adult from two to four drachins (8-15 Cc.) 
every three hours. It is a mistake to wait for signs of debility before 
using alcohol in diphtheria. Strychnines sulphas, in frequent doses, 
should be used from the onset. 

Of drugs, two are warmly advocated ; ferrum and hydrargyrum. 
Of the great value of tincturaferri chloridi there is no question, but 
for hydrargyri chloridum corrosivum it has hardly realized the 
expectations of the profession, except in laryngeal cases. A com- 
bination of ferrum and potassii chloras, in full doses, frequently 
repeated, has seemed, when begun early in the attack, to modify 
the course of the malady, and they have the additional advantage 
of acting locally upon the throat as they are swallowed. A good 
formula is — 

R. Tinct. ferri chlor., n\v-x -3-6 Cc. 

Potassii chlor., gr. iij-v - 2 --3 Gm. 

Glycerini, f.^ ss 2 - Cc. 

Syr. zingib., ad f 3 j— ij ad 4.-8. Cc. M. 

SiG. — In water every three hours, for a child of two or three years. 

Ferrum and hydrargyri chloridum corrosivum, repeated every 
second or third hour, may be combined as follows : 



216 PRACTICE OF MEDICINE. 

H- Hydrargyri chloridi corrosiv. , . gr. ^g- .0015 Gm. 

Tinct. ferri chloridi, TT^v-x .3-. 6 Cc. 

Glycerini, . rr\x .6 Cc. 

Aquae, f 3 j 4. Cc. M. 

Sig. — Every hour or two, well diluted. 

The efficacy of the above is greatly enhanced by the addition to 
each dose of tinctura belladonna, tt^ j-v (0.06-0.3 Cc). 

Quinines sulphas, gr. xvj-xxiv (1-1.56 Gm.) per day for a young 
adult, and gr. v-x (0.3-0.6 Gm.) for a child, should be used through- 
out the disease ; if irritability of the stomach prevent its administra- 
tion by the mouth, it can be used as a suppository, or locally in the 
form of the oleate. 

Sustain the heart with either digitalis, glonoin, caffeines citratce, or 
strychnines sulphas, or a combination of these drugs. 

Calomel in small doses, combined with sodii bicarbonas every hour 
until it is beneficial, and especially in cases showing a tendency to 
spread toward the larynx., Indeed, a tolerance to calomel seems to 
exist in diphtheria of the lary?ix. 

Watch the urme carefully throughout the disease ; diminution in 
the amount with much albumin is of bad omen. The bowels must be 
regular. 

Isolation of the patient and disinfection of the clothing and utensils 
is of importance. All clothing should be soaked twenty-four hours 
and boiled in a two per cent, solution of carbolic acid. 

Inhalatio?is of steam and hot water, and allowing the patient to 
suck pellets of ice, give relief. Sponges dipped in hot water and 
applied to the angles of the jaw are beneficial. 

The chief danger of communication of the poison is the air exhaled 
from the fauces and from the surface. Dr. J. Lewis Smith recom- 
mends the following plan to counteract the danger. Add four ounces 
of the following solution to one quart of water and allow them to 
simmer constantly, near the patient, in a broad surfaced tin or zinc 
wash-basin : R. Olei eucalypt., acidi carbolici, aa 15J (30 Cc.) ; spirit, 
terebinthinae, f^viij (240 Cc). M. The vapor is strong, penetrating, 
and prophylactic, but not unpleasant. In hot weather, or when a fire is 
not convenient, saturate cloths a foot square with the same solution 
and place them on paper on the bed of the patient. 

Locally. Two indications to be met, one to prevent or limit the 
local development of the bacilli, and the other to combat the effects 



ACUTE GENERAL DISEASES. 217 

of the toxic material which the bacilli produce. The first question 
asked is, Can we dissolve the membrane ? " In laboratory, yes ; in 
throat, no." (Da Costa.) 

Cleanliness of the fauces is of the utmost importance, and if a non- 
irritating disinfectant be added, its value is enhanced. Prof. Bar- 
tholow " has seen excellent results from the frequent application of a 
solution of acidam lacticum, strong enough to taste sour, by means of 
a mop." Excellent results are obtained from spraying the throat 
with a fifty per cent, solution of hydrogen peroxide. Swabbing the 
throat with the following is valuable : 

R . Acidi carbolici, TT^xx 1.3 Cc. 

Tinct. ferri chlor., f.^iv T 5- Cc. 

Glycerini, f Jj 30. Cc. 

Aq. destil., f^j 30. Cc. M. 

Sig. — Locally, every three hours. 

Applications of corrosive sublimate to the throat are often valuable. 
Dr. Ernest Laplace has demonstrated that corrosive sublimate in 
solution, slightly acidulated with tartaric acid, has its germicide prop- 
erty increased, as in the following 1-500 solution (R. Hydrargyri 
chlor. corrosiv., gr. 3.85; acid tartaric, gr. 19.25. M.) 

The following, used as a gargle, or applied by a mop, is useful : 

R. Potass, chlorat., t ^iv 15. Gm. 

Acid, carbol., gr. ij-iv .13-. 26 Gm. 

Tinct. myrrh., f^j 30. Cc. 

Inf. cinchonae, f ^ ij 60. Cc. M. 

It is a mistake to struggle with children over their refusal to use a 
gargle or allow the use of the spray, as they do not know how to gargle 
and they are afraid of the spray. Much better to add plenty of 
glycerin to their medicine, and use no liquid for some time after swal- 
lowing. 

For laryngeal diphtheria the same general treatment, especially 
the mercurial, with inhalations of lime by slaking freshly-burned 
lime in a vessel and directing the vapor to the child by a newspaper, 
or some similar contrivance, or using three parts of liquor calcis and 
one part of glycerinum in an atomizer, every half hour or hour, or liquor 
trypsin, as a spray. If these means fail, resort must be had to trache- 
otomy, or intudation of the larynx, which have succeeded in many 
*9 



218 PRACTICE OF MEDICINE. 

desperate cases. It is safer to insert a tube at the onset in all cases 
of laryngeal diphtheria. 

For nasal diphtheria, the same general treatment, and syringing 
the nose every two or three hours with a weak solution of potassii 
chloras, or acidum carbolicum, or hydrogen peroxide, or the follow- 
ing : 

R . Sodii sulphit., giij 12. Gm. 

Glycerini, fgij 8. Cc. 

Aquae, f^i v I2 °- Cc. 

For the paralysis, strychnines sulphas and ferrum internally, or 
strychni?i<z sulphas hypodermically, with the galvanic or faradic 
current locally. 



GLANDERS. 

Synonyms. Farcy ; malleus humidus. 

Definition. An infectious disease of the horse, communicable to 
man and some domestic animals, but not to cattle; characterized by 
nodular growths in the nose — glanders, and under the skin — farcy. 

Cause. Due to a specific bacillus — bacillus Mallei. The organ- 
ism resembles the tubercle-bacillus, though somewhat shorter and 
thicker. Communicated by the discharge from an infected animal to 
an abraded skin or mucous surface. Contagious, hicubation from 
three to five days. 

Pathological Anatomy. Nodules, consisting of aggregations 
of round cells of lymphoid or polymorphonuclear type, which have 
a strong tendency to suppurative or necrotic softening. The floor 
and edges of the ulcers (softened nodules) are irregular and yellow- 
ish, discharging more or less purulent matter. The nodules develop 
particularly in the nares and the skin, and, rarely in the lungs. The 
lymphatic glands of the neck and elsewhere enlarge and may sup- 
purate. 

Symptoms. There is an acute and a chronic form of glanders. 

Acute glanders. Redness and swelling of the nasal mucous mem- 
brane with bur?iing and dryness, followed by the development of the 
nodules, which rapidly break down and discharge a fetid hemorrhagic 
or muco-pus. There is headache, painful deglutition, cough, fever, 
prostration, rapidly developing typhoid symptoms, and death. 



ACUTE GENERAL DISFASES. 219 

Acute farcy or glanders of the skin is a nodular swelling with subse- 
quent ulcers and discharge of a fetid hemorrhagic pus on the skin. 
Papules, becoming pustules, followed by ulceration, occur in the 
neighborhood of the nodules. The lymphatic glands and vessels 
are involved, but not the nose. Prostration and typhoid symptoms 
rapidly develop. 

In the chronic variety the development, course, and symptoms are 
all more backward and of less severity. 

Diagnosis. The certainty of diagnosis is made possible by mak- 
ing cultures. 

Prognosis. Acute variety fatal. Chronic variety, if early diag- 
nosed, many may recover. 

Treatment. Palliative and surgical means for the lesions. It is 
possible the serum-therapy may soon be able to control, cure, or 
modify this fatal disease. 

ACUTE ARTICULAR RHEUMATISM. 

Synonyms. Rheumatic fever; inflammatory rheumatism. 

Definition. A constitutional disease, characterized by fever, in- 
flammation in and around the joints, occurring in succession, and a 
great tendency to inflammation of either the endocardium or peri- 
cardium. 

Causes. The predisposing causes are inherited tendency, scarla- 
tina, and the puerperal state. 

The exciting causes are exposure to cold and chilling of the body 
in those predisposed. Rheumatism rarely occurs before seven or after 
fifty years. The liability to the disease is increased by having had 
an attack. It is claimed that a specific bacteria has been found in 
the swollen joints, which may prove to be the etiological factor in the 
production of the painful affection. 

Pathological Anatomy. The blood contains an excess of lactic 
acid. The joints bear the brunt of the attack ; the synovial mem- 
brane is reddened, the vascularity of the synovial fringes is increased ; 
so with the synovial fluid, which is thinner, of a reddish color, con- 
taining some gelatinous coagula of fibrin, and, under the microscope, 
nucleated cells, ordinary pus cells being rarely seen. 

The swelling visible from the affected part depends mostly on 
inflammatory oedema of the connective tissue around the joint. 



220 PRACTICE OF MEDICINE. 

The pain is probably due, in all cases, to stretching of and press- 
ure on the elements of the tissues by the dilated capillaries and the 
inflammatory cedema. For the changes which ensue when the endo- 
and pericardium are attacked, the reader is referred to the sections on 
those diseases. 

Symptoms. Begins suddenly, generally at night, with a chill ox 
chilliness, pain and stiffness in the joints, loss of appetite, at times 
nausea and vomiting, followed by fever, the temperature soon reach- 
ing io2° to 104 F., in rare cases 108 to no° {the hyperpyrexia), the 
pulse seldom exceeding 95, great thirst, profuse acid sweats, scanty, 
high-colored, acid urine, at times showing traces ■ of albumin ; the 
bowels constipated. The fever continues throughout the attack, show- 
ing marked remissions. Delirium is absent, except the hyperpyrexia 
occur. Sleep is prevented by ike pain and the profuse perspirations. 
The strength is moderately well preserved. 

The skin is often covered with an eruption of miliaria rubra, red 
papules, and miliaria alba, the result of irritation at the orifices of the 
sweat glands, from the excessive perspiration. 

The local phenomena are pain, tenderness, increased heat, swelling, 
and redness of one or more joints ; if but one joint, it is termed 
monoarthritis ; if more than one, polyarthritis. Pain is aggravated 
by ?notion and pressure. Swelling is most apparent in those joints 
not covered with muscle, as the knee, wrist, elbow, ankle, and the 
hands and feet, and is proportionate to the acuteness of the attack. 
The inflammation may abruptly cease at one or more joints, and as 
suddenly attack others. 

The disease is extremely irregular as regards the number of joints 
affected, although the local manifestations are controlled by an 
important pathological law, the law of parallelism. Correspond- 
ing joints are often affected together, and when not, the different 
affected joints are either on one side of the body, or those on both 
sides which are analogous, as the knee, elbow, wrist, ankle, hip, and 
shoulder, are attacked together. 

Complications. Pericarditis, endocarditis, myocarditis, cerebral 
endarteritis, bronchitis, pneumonitis, and pleuritis. 

Duration. The duration of acute rheumatism is governed entirely 
by the presence or absence of complications. Uncomplicated cases 
recover in from thirteen to twenty-one days, although they may be 
prolonged to five or six weeks. Relapses are frequent. 



ACUTE GENERAL DISEASES. 221 

Diagnosis. A typical case cannot be mistaken for any other 
disease, but cases running a subacute course may be mistaken for 
acute rheumatoid arthritis, gonorrhceal rheumatism, or pyaemia. 

Acute rheumatoid arthritis attacks one joint at a time and becomes 
permanent, has slight, if any fever, no sweats or cardiac lesions. 

Gonorrhceal rheumatism is associated with a gleety discharge, or 
follows the sudden cessation of an acute or subacute gonorrhceal 
discharge, attacks either the ankle or wrist only, is slowly influenced 
by treatment, and lacks the febrile phenomena. 

PycEmia is usually manifested at a single joint at the time, and is 
followed by suppuration and all the symptoms of hectic fever. 

Prognosis. Recovery is the rule in uncomplicated cases, the 
mortality being about three per cent. When death occurs, it usually 
depends upon hyperpyrexia, cardiac complication, or cerebral end- 
arteritis. 

Treatment. Owing to our imperfect knowledge of the exact 
nature of this most painful disease, its treatment still remains either 
empirical or is directed toward certain prominent symptoms or com- 
plications. Garrod claims that "colored water" is about as potent 
as anything else, for it is, he says, a "self-limited disease," some- 
times running a long and sometimes a short course. 

Rest in bed, whether the pain forces it or not, is important. 
Warmth is as imperative, for which purpose the patient should be 
kept in blankets — no sheets — and wear woolen garments. The diet 
should be easily digested food, milk being the most suitable. 

Strong and vigorous patients do well with acidum salicylicmn or 
the salicylates in large and frequently repeated doses. 

R. Acidi salicylici, 5ss 15. Gm. 

Liq. ammonii acetat., f 3 iv 120. Cc. 

Spts. setheris nitrosi, f t ^j 30. Cc. 

Syr. simplicis, f j§j 30. Cc. M. 

SiG. — Tablespoonful eveiy three hours, well diluted. 

Or— 

R. Sodii salicylat., • ,lj 3°- Gm. 

Tinct. cinchonae comp. , .... f5iij 90. Cc. 

Aq. menth. pip., f 3 iij 90. Cc. M. 

Sig. — Dessertspoonful every three or four hours till relief, when widen 
the interval. 



222 PRACTICE OF MEDICINE. 

Or— 

R . Potassii acetat., %] 30. Gm. 

Acid, salicylici, . !|ss 15. Gm. 

Syr. limoms, .*•... fjfij 60. Cc. 

Aq. menth. pip., fj viij 240. Cc. M. 

Sig. — Tablespoonful every three hours, diluted. 

If benefit follows, the evidence is quickly afforded in the relief of 
pain and the decline of the temperature and swelling. If, therefore, 
after three or four days' use of the salicylates or acidum salicylicum, 
as above recommended, signs of improvement are wanting, the treat- 
ment had better be changed for the alkaline treatment, which consists 
in the administration of an ounce and a half of the alkaline carbon- 
ates, either alone or with a vegetable acid, each twenty-four hours, 
until the urine becomes neutral or alkali?ie ) when the quantity is 
reduced to an amount sufficient to maintain alkaline urine. 

The following are good formulae for the alkaline treatment: 

5t . Potassii bicarbonatis, gij 8. Gm. 

Acid, tartarici, gr. xxx 2. Gm. 

Dissolve in a glass of water and drink effervescing every three hours. 

Or— 

R. Potass, bicarb., gij 8. Gm. 

Succi limonis, . . . fgiv 15. Cc. 

Aquae chloroformi, f^ ss 1 5- Cc. M. 

Sig. — In water, every three hours. 

After the more acute symptoms are relieved change whichever 
plan of medication has been used for tinctura ferri chloridi, rr\,xx 
(1.3 Cc), every three or four hours, well diluted, or for full doses of 
Basham's mixture. 

Pale, feeble, and anaemic patients, or attacks following scarlatina 
are most favorably influenced by — 

R. Strychninre sulph., gr. jfc .001 Gm. 

Tinct. ferri chlor., tt^xv-xxx I. -2. Cc. 

Liquor, ammonii acetat., . . . . f^ss 15. Cc. M. 
Sig. — Every four hours, in a glass of water. 

Dr. S. Solis-Cohen has reported good results from the following 
combination in anaemic and run down cases, to which he has given 
the name of " mistura ferro-salicylata " : 



ACUTE GENERAL DISEASES. 223 

R. Sodii salicylates, £iv 15. Gm. 

Glycerini, f^j 30. Cc. 

Acidi citrici, gr. x .6 Gm. 

01. gaukheriae, f?> ss 2 - Cc. 

Mucil. acacias, f§ ss x 5- Cc. 

Misce et adde while stirring, 

Tinct. ferri chlorid., ^^ 1V 1 5- Cc. M. 

Liq. ammonii citrat. (B. P.), ad 13 iv ad 120. Cc. 
Sig. — One to two teaspoonfuls every two, three, or four hours, diluted. 

Prof. Da Costa reports a lessened proportion of cardiac compli- 
cations with ammo7iii bromidum, gr. xv-xx (1-1.3 Gm.), every four 
hours. I much prefer ammonii salicylas, gr. x-xv (0.6-1 Gm.), in 
simple syrup, well diluted, every four to six hours. 

Subacute attacks and lingering cases are favorably influenced by 
cinckonidincz salicylas, gr. v (0.3 Gm.), every four hours, or — 

r£ . Lithii salicylatis, gr. xv-xx 1.-1.3 Gm. 

Syr. zingiberis, f^j 4. Cc. 

Aq. lauro-cerasi, fgj 4. Cc. M. 

Every four hours. 

Or— 

R. Potassii iodidi, ^iv 5.3 Gm. 

Sodii salicylatis, %'w 15. Gm. 

Elix. cinchonas, f^iss 45. Cc. 

Infus. gentianas, f ^ iss 45. Cc. 

Aquae destil., f 3J 30. Cc. M. 

SlG. — Dessertspoonful every three or four hours, diluted. 

Good results are reported from the use of salol, gr. v-x (o. 3-0.6 Gm.), 
every four hours, from aminonii hydrochloras, gr. xv-xx (1— 1.3 Gm.), 
every four hours, and from salipyrin in solution, every four hours ; 

R. Salipyrin, giij 12. Gm. 

Glycerini, f^iij I2 - Cc. 

Syr. aurantii, f.^ v j 2 4- Cc. 

Aquas destil., adf^vj ad 180. Cc. M. 

SlG. — Tablespoonful, well diluted. 

Whichever plan, acidum salicylicum, salicylates, alkaline, or fer- 
rum, is adopted, quinince sulphas, gr. xv (1 Gm.), per day, should 
also be used. 

Pain and restlessness should be controlled by opium in some form, 
in full doses, or atropine sulphas, gr. -^ (0.0008 Gm.), hypodermic- 
ally. 



224 PRACTICE OF MEDICINE. 

For the hyperpyrexia, quinince sulphas, gr. xxx-lx (2-4 Gm.), 
repeated p. r. n., with the cold bath or wet pack. 

Locally, the affected joints should be wrapped in cotton-wool or 
flannel, saturated with a solution of linctura opii, one part, and liq. 
plumb, subacetat. dil., two parts, or olei gaultheritz, fgj (4 Cc), with 
lin. saponis comp., f^iij (o/rCc), or — 

R. Sodii bicarbonatis, :fij 60. Gm. 

Tinct. opii, f.3 ss *5- Cc. 

Aquae bul., 6ij 960. Cc. M. 

Dr. Bartholow finds the application of blisters an effective 
method. He says : " I have small blisters, the size of a silver dollar, 
placed around the joint, leaving an interval between for succeeding 
applications. It is by no means so painful and disagreeable as it 
appears at first sight. The blisters remarkably relieve the pain, bring 
about a more alkaline condition of the blood, and render the urine 
less acid, or bring it to neutral, or even to alkaline." 

If the disease shows a tendency to linger in one or more joints, such 
joints should be immediately placed in the hot-air apparatus. 



MUSCULAR RHEUMATISM. 

Synonyms. According to location : cephalodynia ; lumbago ; 
torticollis ; pleurodynia. 

Definition. An affection of the voluntary muscles, inflammatory 
in character, either acute or chro7iic ; characterized by pain, tender- 
ness, and stiffness of the affected muscles. It is never complicated 
with cardiac disease. 

Causes. A disease of adult life. One attack predisposes to an- 
other. Almost always due to cold or damp, or direct draught of cold 
air. Gout increases the tendency to attacks. 

Pathological Anatomy. The true nature of muscular rheu- 
matism is not yet determined. Virchow suggests a " hyperemia of, 
and scanty serous exudation between, the muscular striae, and in 
chronic cases inflammatory proliferation of the connective tissue." 

Symptoms. The first attack is generally acute. Onset rather 
sudden, with pain in the affected muscles, with slight tenderness, and 
considerable stiffness and difficulty of move?nent, by which also the 
pain is increased. 






ACUTE GENERAL DISEASES. 225 

The suffering may be severe and constant, or only on motion. 
Spasm of the affected muscles may occur. Objective symptoms are 
wanting, except it is evident that the patient keeps the affected 
muscles as quiet as possible. Fever is absent. The pain may pre- 
vent sleep. 

Duration, acute form, about one week. Chronic variety returns fre- 
quently, and finally becomes constant and aggravated when the 
weather is damp. 

Varieties. It may affect any or all of the voluntary muscles, but 
its most frequent and important varieties are : 

1. Cephalodynia. Situated in the occipito-frontal muscles. Dis- 
tinguished from neuralgia of the trifacial, or occipital nerve, by pain 
on both sides of the head, excited or aggravated by the movements 
of the muscle and by absence of disseminated points of tenderness. 

The muscles of the eye may be affected, and movements of that 
organ excite pain. If the temporal and masseter muscles are 
attacked, mastication excites pain. 

2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- 
mastoid muscles. Generally limited to one side of the neck, toward 
which side the head is twisted, great pain being excited on attempting 
to turn to the opposite side. Rheumatism of the muscles of the back 
of the neck, cervicodynia, may be mistaken for occipital neuralgia. 

3. Pleurodynia. Situated in the thoracic muscles, and may be 
mistaken for pleuritis, or intercostal neuralgia, from which it is differ- 
entiated by the absence of the diagnostic features of each. Pain is 
excited by forced breathing, coughing, and sneezing. 

4. Lumbodynia or lumbago. Situated in the mass of muscles and 
fasciae, which occupy the lumbar region. Most common variety. 
Usually affects both sides. It may set in rapidly, and become very 
severe. Motion of any kind aggravates the pain, often becoming 
very sharp or stabbing in character. It is sometimes complicated 
with acute sciatica, when the suffering is agonizing. 

Diagnosis. The different varieties may be mistaken for any of 
the following ailments, to wit : trifacial, occipital, or intercostal neu- 
ralgia, pains of progressive muscular atrophy, neuritis, syphilis, 
metallic poisons, or painful affections of the loins, arising from calculi 
or gravel in the kidney. 

A careful examination of the history is usually sufficient to arrive 
at a correct diagnosis. 
20 



926 PRACTICE OF MEDICINE. 

Prognosis. Difficult to eradicate, and in chronic cases to amelio- 
rate, but is not dangerous to life. Death never results. 

Treatment. Rest is the first indication. This is accomplished 
in pleurodynia by firmly strapping the affected side with broad strips 
of plaster, extending from mid-spine to mid-sternum. 

The /^^/application to the affected muscles of hot poultices, made 
of two-thirds pilocarpus leaves and onz-\ki\xdi flax seed meal, changing 
them every two hours, is the most rapidly successful treatment in acute 
cases. 

Internally, antipyrin, gr. x-xx (0.6-1.3 Gm.), repeated in several 
hours, or ammonii hydroc Moras, gr. xv-xx (1— 1.3 Gm.), every three 
hours, or sodii salicylas, gr. xv-xx (1— 1.3 Gm.), every two or three 
hours, are each of value. Prof. Bartholow declares that lithii 
bromidum is almost a specific in muscular rheumatism. 

For the pain and consequent sleeplessness, use — 

R . Pulv. ipecac, et opii, gr. x .6 Gm. 

Potass, nitrat., gr. v-x .3-.6G111. M. 

SiG. — In powder, morning and night. 

Or, hypodermically, at the seat of pain, morphines sulphas, gr. yi- 
% (0.008-0.016 Gm.), and atropines sulphas, gr. -fa (0.0008 Gm.), 
p. r. n. 

In attacks where the disease is limited to a few muscles, the follow- 
ing liniment is valuable : 

R. 01. gaultherise, giss 6. Cc. 

Spirit, vini rectif., . . . • ■ ■ . f^ij 60. Cc. M. 

Sic*. — Thoroughly rub into affected part. 

In all forms, but more particularly in lumbago, a few dry cups over 
the seat of the pain give immediate relief. 

Wonderful results have followed the use of the hot-air apparatus 
in acute and subacute lumbago. 

Chro?iic cases : Rest, flannel worn next to the skin, stimulating and 
anodyne liniments, mild galvanism, dry heat, as ironing over the 
affected part with a common flat-iron, a piece of paper or towel 
being placed next to the skin. 

Internally, potassii iodidum, ammonii hydrochloras, sulphur, guai- 
acum or arsenicum variously combined. 



ACUTE GENERAL DISEASES. 227 



RHEUMATOID ARTHRITIS. 

Synonyms. Arthritis deformans ; rheumatic gout (?). 

Definition. A destructive disease of the joints, accompanied 
with but slight fever, without suppuration ; progressive in character, 
causing nearly symmetrical enlargement and deformity of various 
articulations. 

Causes. The neuro-trophic theory, as advocated by Mitchell 
(J. K.) and supported by Charcot, is accepted as the predisposing 
cause. Among the exciting causes are bad hygiene, exposure, injury, 
prolonged lactation, frequent pregnancies, menopause, grief, tuber- 
cular diathesis, and following attacks of articular rheumatism. More 
common in women than men. A disease of middle life. 

Pathological Anatomy. It is not rheumatism, as the blood 
contains no lactic acid. It is not gout, as uric acid is not found in the 
blood nor urate of sodiwn in the joints. 

At first rheumatoid arthritis is attended with hyperemia of the 
affected synovial membrane and increase of the synovial fluid. Soon 
the capsular ligament becomes irregularly thickened, the synovial 
fluid decreasing. If the process continue, the internal ligament is 
destroyed, thus allowing dislocation to occur. The interarticular 
fibro-cartilages ulcerate and disappear, as do the cartilages covering 
the ends of the bone, the ends of the bones becoming smooth and 
eburnated, and often greatly enlarged. 

Symptoms. Either acute or chronic, the latter more frequent. 

Acute form, involves several joints at the same time, and is attended 
with slight pyrexia. 

Chronic form slowly involves one joint, which seemingly soon 
recovers, and is attacked again, and may never recover, but grows 
progressively worse. 

The joint slowly enlarges, is painful, movement exciting neuralgic 
pains along the limb. Soon the articulations become rigid or slightly 
movable after prolonged attempts, are more or less distorted and 
flexed, with nodules (Heberden's nodosities) on the sides or ends of 
the distant phalanges. Redness and tenderness are wanting. The 
muscles of the affected limb waste, giving the joint a greatly hyper- 
trophied appearance. Crepitation is distinct after ulceration has 
destroyed the cartilage. 



228 PRACTICE OF MEDICINE. 

The hands are first involved, the disease spreading symmetrically 
from articulation to articulation, until in severe cases every joint is 
deformed. 

Diagnosis. Chronic articular rheumatism is often confounded 
with rheumatoid arthritis ; but the former lacks the marked structural 
changes and the progressive involvement of joint after joint. 

Gout differs from rheumatoid arthritis by the presence of deposits 
of urate of sodium in the joints, the ears, tips of fingers, and the 
bursae over the olecranon process of the elbow, the presence of uric 
acid in the blood, and the decided history of acute paroxysms. 

Gonorrheal rheumatis?n, so-called, has symptoms akin to rheu- 
matoid arthritis, but the history of urethral suppuration clears up the 
diagnosis. 

Paralysis agitans, when pronounced, might be confounded with 
rheumatoid arthritis if the examination were limited to the joints; 
but the whole history, such as the tremor, the gait, etc., should pre- 
vent error. 

Prognosis. If early treatment be instituted, the disease may be 
held in abeyance for several years. After pronounced structural 
changes have begun, the malady is incurable, although it may 
remain stationary for a long time. 

Treatment. If treatment be instituted before serious structural 
lesions have occurred, the author has seen benefit in many cases by 
the following plan : Oleum morrhuce carefully and thoroughly rubbed 
into the affected joints three times a day, with the internal use of lithii 
citras effervescentes, Z] (4 Gm.), three times a day, and the following 
tonic mixture : 

R. Massse ferri carbonat., gr. v .3 Gm. 

Liquor, potass, arsenit., .... rr^v .3 Cc. 

Vini xerici, f^j 4. Cc. 

A quae distill., f 3J 4. Cc. 

After meals, well diluted. 

I have had some success from painting the joints when painful 
with the following combination, using at the same time guaiacol 
carbonat., gr. v-x (0.3-0.6 Gm.), three times daily : 

R. Guaiacol, I part 

Tinct. iodi, 6 parts. M. 

Sig. — Paint over joints twice daily. 



ACUTE GENERAL DISEASES. 229 

Complete recoveries are reported from the long-continued adminis- 
tration of small doses of liquor potassii arsenitis. 

Attention to diet and hygiene are most important and valuable. 
When structural changes have destroyed portions of the joint, pallia- 
tive treatment is the chief indication. 



GOUT. 

Synonyms. Podagra, gout in the foot; chiragra, the hand; 
gonagra, the knee. 

Definition. A constitutional disease, usually inherited ; charac- 
terized by the sudden occurrence of a paroxysm of severe pain and 
swelling in one of the smaller joints, — the great toe usually, — with the 
presence of uric acid in the blood, and the deposit of the urate of 
sodium in the structure of the joint. 

Causes. Predisposing : inherited, male more than female — 
women after menopause. 

Exciting; malt liquor and wine drinking; large consumption of 
animal food ; lead poisoning ; winter season. 

When an inherited tendency, may begin early in life; when an 
acquired tendency, after thirty-five years. 

The pathological cause consists in the presence of an excess of uric 
acid in the blood in the form of urate of sodium. 

Pathological Anatomy. Gout is characterized by the deposit 
of urate of sodium from the blood into the structure of joints and 
tissues that are not very yascular. The deposit is associated with 
signs of inflammation — to wit : hypersemia, redness of the surface, 
with swelling and effusion in and around the affected joint. The 
surfaces of the joint are incrusted with chalk-like masses, consisting 
of urates, which become greater with each attack, finally causing 
great deformity. 

The deposit usually begins in the metatarso-phalangeal joint of the 
great toe, but other and many joints are soon affected. 

The deposits may also be found in the knuckles, eyelids, and car- 
tilages of the ear. 

" Crystals of urate of soda are deposited in the tubules and intra- 
tubular tissues " of the kidneys — " gouty kidney " — and may be seen 
by the naked eye, the kidneys becoming small, granular, and fibrous. 



230 PRACTICE OF MEDICINE. 

Hypertrophy of the left ventricle and of the arteries, ending in 
atheromatous changes, are results of gout. 

Symptoms. Acute gout is rare in the United States. It occurs 
in paroxysms ; one year's interval between the first and second 
attack ; six months usually between the second and third, after which 
it may occur at any time. 

Prodromes usually precede the paroxysm for several days, to wit, 
acid dyspepsia, constipation, headache, and lassitude. 

The paroxys?n begins suddenly, between midnight and 2 A. M., 
with acute pain in the ball of the great toe, which becomes red, hot, 
swollen, and so sensitive that the slightest touch cannot be borne. 

The veins are filled, the foot, ankle, and leg swollen, and the limb 
the seat of sudden spasmodic contractions, which increase the suffer- 
ing ; slight relief is afforded by elevating the limb. Associated with 
the local symptoms are chill, fever, quickened pulse, thirst, coated 
tongue, constipation, and scanty, acid, high-colored urine, which de- 
posits, on cooling, a heavy brickdust sediment. 

Towards daylight the symptoms ameliorate, to return again at sun- 
down, the severity gradually lessening, until the fourth or fifth day, 
when convalescence is established, the patient, as a rule, feeling better 
than before the attack. 

Chronic Gout. Either the result of acute attacks or with a greater 
number of joints being attacked. 

The paroxysms occur at any time, but develop slowly, with less 
pronounced local and general symptoms. Deposits are noticed, the 
joints becoming hard, knobby, and often distorted. The deposit's or 
chalk stones (urate of sodium) occur about the joints, tendons, and 
bursse, and helix of the ear. 

Diagnosis, An error cannot occur if the history of the case can 
be obtained, to wit : hereditary tendency, age, sex (females rare, until 
menopause), mode of living, character of symptoms, and presence of 
the characteristic deposits. 

Prognosis. Acute gout rarely fatal ; is prone to return, but much 
depending upon the mode of living. 

Chronic gout decidedly shortens life. The most serious signs are 
those indicating advanced renal disease, with non-elimination of uric 
acid. Gout influences unfavorably the prognosis from acute diseases 
or injuries. 

Treatment. For the acute paroxysms, at once, vinum colchici 



ACUTE GENERAL DISEASES. 231 

radicis, gtt. xv-xx-xxx (1-1.3-2 Cc), every two hours, well diluted, 
either alone or in combination with a potassium salt, or sodiisalicylas, 
gr. xx (1.3 Gm.), every two to four hours, well diluted, until relief or 
ringing in the ears occurs. While the acute symptoms of gout are 
not so rapidly relieved by sodii salicylas as are those of acute rheu- 
matism, still it is an invaluable remedy and is rapidly succeeding 
colchicum. After the decrease of the acute symptoms, lessen the 
dose, but continue the remedy for some time. 
Dr. Bartholow recommends the following pill : 

Be. Colchicine, gr. -£§ .0013 Gm. 

Ext. colocynth. comp., gr. ss .032 Gm. 

Quininae sulph., gr. lij .2 Gm. M. 

Every two or three hours. 

For the pain, hypodermic injection of morphines sulphas, and 
wrapping the inflamed joint in cotton-wool saturated with liq. plumb, 
subacetat. dil. and tinctura opii. The use of morphia in acute gout 
must be with caution, as many subjects have more or less contracted 
kidneys. 

The diet must be restricted to milk and non-acid fruits, raw or 
cooked. The drinking of several ounces of water, hot or natural, 
every three hours, is most useful. 

For subacute or lingering cases, and in chronic gout, potassii iodi- 
dum is valuable. 

U . Potassii iodidi, £ij 8. Gm. 

Vini colchici radicis, f ^ iv 15. Cc. 

Aquae destil., fjjiiss 75. Cc. M. 

SiG. — Teaspoonful, well diluted, after meals and at bedtime. 

For chronic gout, regulated diet, free action on the secretions, and 
lithii cilras effervescentes, Z) (4 Gm.), three or four times a day, well 
diluted with water ; and perhaps a course of quini?ia, ferrum, and 
arsenicum. 

To prevent paroxysm, keep secretions acting by the free use of 
pure water or a good alkaline water, such as Buffalo lithia or Farm- 
ville lithia water, or Saratoga Vichy. 

The diet is of the greatest importance, and should consist chiefly 
of vegetables and fruit, excepting tomatoes and strawberries, lemons 
and oranges ; fresh meat must be discontinued for a time ; oysters, 
fish, and soups may be used sparingly. Alcoholic and malt liquors 



232 PRACTICE OF MEDICINE. 

are contraindicated, as are tea and coffee ; milk should replace ail 
the above. No eggs or dishes containing eggs ; no pastry, hot bread, 
or cakes; no sweetmeats, spices, or condiments. 

Systematic exercise, especially walking, is of great advantage. 

Cold bathing with caution, while the vapor or Turkish baths are 
of benefit. 

Changing from a cold to a warm climate in winter, and the use of 
flannel underclothing, are strongly recommended. 

DIABETES MELLITUS. 

Synonyms. Glycosuria ; melituria. 

Definition. A chronic affection characterized by the constant 
presence of grape sugar in the urine, an excessive urinary discharge, 
and the progressive loss of flesh and strength. 

Causes. Most common in males. More frequent in the Hebrew 
than the Christian. Rare in negroes. Occurs at all ages, but most 
frequently between twenty-five and fifty years. It is often hereditary. 
Disorders of the nervous, hepatic, and renal systems. Excessive use 
of farinaceous food and malt liquors. Sexual excesses. 

The exact pathology of diabetes mellitus differs in different cases, 
and in the present state of knowledge no exclusive view can be 
adopted. Still, there are reasons for believing that, in a large pro- 
portion of cases, the nervous system is primarily at fault, though the 
character of the lesions may differ. Pavy believes diabetes mellitus 
originates in the nervous system, and probably as a vaso-motor 
paralysis. Disease or extirpation of the pancreas is followed by 
diabetes, and it is claimed the pancreas secretes a glycolytic ferment. 

Pathological Anatomy. None peculiar to diabetes is yet 
recognized. 

Hyperemia and hypertrophy of the liver and kidneys are gener- 
ally present, the result of increased functional activity. Various 
organic changes are found in the pancreas. 

The changes in the lungs peculiar to phthisis are often found in 
very chronic cases. 

The changes in the nervous system are not fully determined. 

Symptoms. Clinically, cases differ greatly in their course and 
severity ; one class presenting slight symptoms and a chronic course; 
another class having marked local and constitutional symptoms and 



ACUTE GENERAL DISEASES. 233 

running an acute course. The symptoms of a typical case may be 
arranged under the following heads : 

Urinary Organs and Urine. Micturition more frequent and the 
urine increased 'in quantity. Pain over the region of the kidneys. 

The quantity of urine may amount to 4, 8, 12, 20, or 30 pints in 
twenty-four hours. It is usually pale, clear, and watery, having a 
sweetish taste and odor, the specific gravity ranging from 1.025 to 
1.050. It ferments rapidly if kept in a warm place. It yields grape 
sugar to the usual tests, the amount present varying from an ounce to 
two pounds in the twenty-four hours. 

The urea and uric acid are increased. Albumin may be present. 

The increased passage of a large quantity of saccharine urine causes 
a constant itching, burning, and uneasy sensation at the prepuce, 
along the urethra, and at the neck of the bladder; in females, itching 
and eczema of the vulva are common ; in children, incontinence of 
urine is frequent. 

Digestive Organs. An almost constant symptom is thirst, with a 
dry and parched condition of the mouth. At times the appetite is 
excessive, again absent. The breath may have a sweetish odor, the 
tongue irritable, red, and often cracked. Dyspeptic symptoms are 
common, and occasionally vomiting. The bowels are constipated, 
the stools pale and dry. At times diarrhoea may occur. 

The patient complains of feeling very weak, languid, and of sore- 
ness and pai7i in the limbs ; there is more or less emaciation, a harsh, 
dry skin, the countenance distressed and worn. 

The mind is often greatly altered ; depression of spirits, decline in 
firmness of character and moral tone, with irritability, are present. 
Sexual inclination and power are greatly diminished. Defects of 
vision are present. 

The blood and various secretions contain sugar. 

Complications. Pulmonary phthisis ; Bright's disease ; defects 
of vision from atrophy of the retina or the formation of a soft cataract ; 
boils and carbuncles, and chronic skin affections, such as psoriasis 
and eczema. 

Course. The clinical history varies in different cases. In the 
majority of instances the course is chronic, lasting for years, the 
symptoms beginning insidiously, and becoming progressively worse, 
with, at times, decided remissions. Occasionally the disease runs an 
acute course, death occurring within four or five weeks. 



234 PRACTICE OF MEDICINE. 

Termination. The majority of cases ultimately prove fatal, the 
symptoms markedly changing, the urine and sugar diminishing 'in 
quantity, the occurrence of albuminuria, disgust for food and drink, 
and the development of hectic fever and colliquative diarrhoea. 

The fatal result usually arises from gradual exhaustion from blood- 
poisoning, leading to stupor, ending in co7nplete coma, or occasionally 
to delirium or convulsions, or from complications. 

Rarely death occurs suddenly from urcemic convulsions or uramic 
coma. 

Diagnosis. Diabetes mellitus only exists when grape sugar is 
permanently present in the urine. " It is not the quantity, but the 
persistence of sugar which constitutes diabetes." 

With grape sugar in the urine, associated with more or less in- 
crease in the urinary flow, it should be mistaken for no other affection. 

From Bright' 1 s disease, by the absence of dropsy, and of tube casts 
in the urine, and the constant presence of sugar in the urine ; but the 
amount of albumin in the urine is never so great or constant in dia- 
betes mellitus as in Bright's disease. 

From diabetes insipidus, by the absence of sugar in the blood and 
urine, and the larger quantity of urine voided in polyuria. 

Simple glycosuria differs from diabetic glycosuria in that the 
amount of sugar in the urine is not constant, — at one time being pres- 
ent, at another absent, — the amount of urine voided is never in excess 
of health; simple glycosuria is a disease of the aged; diabetic glyco- 
suria usually appears under fifty years. Simple glycosuria often 
results from the inhalation of chloroform, the excessive use of chloral, 
and in the insane, also from excitement, or as one of. the results of 
injuries to the head. 

Prognosis. Most unfavorable as regards a cure, it being fairly 
questionable if complete recovery has ever occurred in a typical case. 
Still, decided amelioration may take place in the symptoms, and the 
progress of the malady be greatly retarded. The younger the patient, 
the more rapid the fatal termination. 

Treatment. Impress upon patients the importance of a strictly 
regulated diet. Prohibit or restrict the consumption of such articles 
as contain sugar or starch, especially ordinary bread or flour, sugar, 
honey, potatoes, peas, beans, rice, arrowroot, cracked wheat, oat- 
meal, turnips, beets, corn, and carrots, prunes, grapes, figs, bananas, 
pears, apples, and liquors of all kinds, whether distilled or fermented. 



ACUTE GENERAL DISEASES. 235 

The main diet should be of animal food, including meat, poultry, 
game, and fish. 

A moderate amount of fluids should be allowed, and in a majority of 
cases milk will prove beneficial, although, theoretically, contraindi- 
cated. Tea, coffee, and cocoa, without sugar, may be allowed in moder- 
ation, glycerin or saccharin being used as a substitute for the sugar. 

Regulated exercise is of importance. The patient should wear 
flannel, and have two or three warm baths every week, or an occa- 
sional Turkish bath. 

Therapeutical treatment. It is difficult to estimate correctly the 
action of any drug in this disease, for, as is well known, a proper modi- 
fication of the diet will alone produce the most marked improvement. 

Opium exercises an influence over the excretion of sugar, but the 
effect is not always maintained. Pavy strongly urges the use of 
codeina in doses of gr. ss-iij (0.032-0.2 Gm.), three times a day, 
gradually increased. "The use of morphines hydrochloras, gr. j (0.065 
Gm.), daily, or pulvis opii, gr. iij-v (0.2-0.3 Gm.), daily, is a favorite 
prescription. Prof. Da Costa suggests the use of ergota, which has 
decreased the urinary discharge and the quantity of sugar in a number 
of cases. Prof. Bartholow has met with an apparent cure by ammonii 
carbonas. Uranii nitras, gr. iij (0.2 Gm.), three times daily, will 
often markedly reduce the urine and sugar, and sodii salicylas, gr. xv 
(1 Gm.), three times daily, will markedly control the formation of 
sugar. Liquor bromini arsenitis, TT^iij-v (0.2-0.3 Cc), three times a 
day, often gives good results. Dickinson remarks that " strychnina is, 
of all remedies, the most constantly useful." Potassii bromidmn, 3j 
(4 Gm.) during the twenty-four hours, is strongly urged. The fol- 
lowing remedies are recommended by different observers — to wit: 
pepsinwn, liquor potassii arsenitis, iodum, potassii iodidum, acidum 
lacticum, glycerinum, quinina, and tine tura cannabis indices. Cures 
are reported from pulvis jambul seeds, gr. v-x (0.3-0.6 Gm.), three 
times daily. Also methylene blue, gr. viij (0.52 Gm.), per diem. The 
evidence in favor of the majority of these drugs is far from satisfactory. 

For diabetic coma, alkalies are particularly indicated. Sodium 
carbonas subcutaneously, or by intravenous injection, watching 
closely the effect on pulse and heart, as recommended by Stabel- 
man. The use of large quantities (quarts) of the normal salt solution 
by means of hypodermoclysis, and slowly thrown into the large bowel, 
is a most valuable aid to elimination. Use also inhalations of oxygen 
and diuretics and fluids to promote elimination of toxic products. 



236 PRACTICE OF MEDICINE. 

Symptomatic treatment is mostly called for. For emaciation and 
anaemia, ferritin and oleum morrhuce ; for sleeplessness and restless- 
ness, morphi?i<z sulphas, potassii bromidum, chloi'al, or hyoscince 
hydrobromas. For boils and carbuncles, calcii sulphidum. Duchenne 
suggests the following solution for the excessive thirst of diabetic 
patients : 

R . Potassii phosphat. , two parts. 

Aquae, seventy-five parts. 

SiG. — One teaspoonful twice or thrice daily, in wine or hop tea. 

The dyspepsia and lung symptoms must be managed on general 
principles. „ 

The constant galvanic current has been productive of good results. 
A change of scene and air is beneficial. 

Surgical operations should on no account be undertaken on diabetic 
patients. 



DIABETES INSIPIDUS. 

Synonyms. Polyuria ; polydipsia. 

Definition. An affection characterized by the excessive secretion 
of a very large quantity of pale, watery urine, free from albumin and 
sugar. 

Causes. Occasionally hereditary, or diabetes mellitus may have 
existed in the parent; more common in children or young adults; 
men are more liable than women ; injuries and diseases of the ner- 
vous system ; hysteria ; exposure to cold ; drinking freely of cold 
water ; fatigue ; prolonged debility ; malaria ; syphilis. 

The probable immediate cause of the excessive secretion of urine 
consists in dilatation of the renal vessels, the result of paralysis of 
their muscular coat, caused by derangement of innervation, as the 
condition can be induced experimentally by irritating a spot in the 
fourth ventricle, or by section of portions of the sympathetic nerve. 

Symptoms. The affection is characterized by great thirst, with 
an increased flow of pale, watery, slightly acid urine, the amount 
varying from one to five or six gallons in the twenty-four hours. The 
specific gravity ranges from i .001-1.007. Sugar and albumin are 
absent. Urea and the other solids are increased. The appetite is 
voracious, the bowels are obstinately constipated, and the skin is dry 
and harsh. 



ACUTE GENERAL DISEASES. 237 

The large flow of urine is usually preceded by various nervous 
phenomena, as nervousness, irritability , inability to concentrate the 
mind, vivid imagination, a failure of memory, and headache. 

Unless the affection is soon arrested, great loss of flesh and strength 
result. 

Diagnosis. It differs from diabetes mellitus by the absence of 
grape sugar in the urine. 

From paroxysmal diuresis, by the absence of the increased urine 
permanently. 

From interstitial nephritis, by the greater amount of urinary dis- 
charge and the absence of albumin, oedema, and casts, and the 
cardiac and vessel changes. 

Prognosis. Rather unfavorable as to a radical cure, unless caused 
by syphilis. Death rarely is due to the diabetes, but to some inter- 
current malady that the patient has been unable to withstand, on 
account of the weakness produced by the diabetes. 

Treatment. If due to syphilis, potassii iodidum and hydrargyrum 
are of real benefit. Prof. Da Costa has had success with ergota in the 
form of the fluid extract or the aqueous extract. Pilocarpus has been 
used with success. Prof. Bartholow recommends galvanism in cases 
not cured by potassii iodidum, placing " one electrode to the neck 
below the occiput, the other to the hypochondriac region in turn." 
Valeria?i, potassii bromidum, and sodii salicylas have been used. The 
author has effected a cure in three cases, where other remedies had 
failed; by the use, internally, of — 

& . Strychninae sulphatis, gr. ^ .0015 Gra. 

Acid, hydrochlor. dil., TT\,x .6 Cc. 

Aquae lauro-cerasi, fgij 8. Cc. M. 

Well diluted. 

The obstinate constipation is best overcome by pilules catharticce 
compositce, one at bedtime. 



LITUJEMIA. 

Synonyms. Lithiasis ; uric acid diathesis ; uricaemia ; American 
gout. 

Definition. A condition to which the fluids of the body are satu- 
rated with nitrogenized waste, in the form of lithic or uric acid ; 
characterized by marked dyspepsia, various nervous phenomena, 



238 I RACTICE OF MEDICINE. 

muscular and articular pains, bronchial catarrh, all or any of these 
associated with scanty, high-colored, acid urine. 

Causes. High living, with little exercise ; imperfect digestion of 
nitrogenized food; impaired elimination of uric acid. The direct or 
remote offspring of the gouty are most frequently the victims. 

Pathology. Not yet clearly determined. The non-elimination 
of certain products which have a deleterious influence upon the 
nervous system. That uric acid does exist in the blood is now gen- 
erally accepted. 

Symptoms. Those of dyspepsia, associated with irregular 
bowels, scanty, high-colored, acid urine, sp. gr. i. 024-1. 028, contain- 
ing neither sugar nor albumin, but showing an increased proportion 
of urates or uric acid, or both, and oxalate crystals. Also depressed 
spirits, impaired memory, loss of interest in occupation, sleepless nights, 
attacks of vertigo, neuralgic pains in the head, and a constant dread 
of apoplexy or cerebral disease. Also pains in the joints, neuralgic in 
character, and in the dorso-lumbar region and right scapular region. 

If the condition be allowed to continue, the following organic 
changes may result — to wit : fatty heart ; fibroid kidney ; enlarged 
liver, or changes in the cerebral vessels. 

Diagnosis. From gout, by the absence of acute paroxysms and 
resulting changes in the joints. 

Prognosis. If properly recognized and treated, complete recov- 
ery will result, although it is a disorder of long duration. 

If not properly treated, develops some one of the organic diseases 
mentioned. 

Treatment. Regulated diet, using fresh meat once daily, poultry, 
game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, 
spinach, celery, cold slaw, and tomatoes ; avoid all kinds of starchy 
and saccharine foods, also all stimulants, tea and coffee, using milk, 
skimmed milk, or milk and cream. Act freely on all the secretions, 
particularly the liver and kidneys. Systematic exercise. Avoid 
tonics, bromides, chloral, and opium. Long course of alkaline waters, 
particularly the lithia waters. Intestinal antiseptics are valuable, such 
as salol, gr. j (0.065 Gm.) three times daily, or potassii permanganas, 
gr. j (0.065 Gm.) in coated pills after meals. Good results follow 
HtJiiicitras, gr. xx (1.3 Gm.), t. d., sodii phosphas, gr. xxx-lx (2-4 Gm.), 
ter die, or acidum benzoicum, gr. x (0.6 Gm'.), t. d. , all well diluted 
with water. One of the very best drugs is acidum nitricum dilution, 



ACUTE GENERAL DISEASES. 239 

tt\,x (0.6 Cc.) in half a glass of water, four times a day, with the occa- 
sional use of pilules rhei composites at bedtime. Considerable success 
has been obtained with piperazine, gr. x-xv (0.6-1 Gm.) in solution, 
after meals. Strontium has acted nicely in several cases. 

B . Strontii bromidi purse, gr. xxx 2. Gm. 

Glycerini, n\,xxx 2. Cc. 

Infus. gentianse, fgiss 6. Cc. M. 

Sig. — Before meals, well diluted. 

CHOLERA. 

Synonyms. Epidemic cholera; Asiatic cholera; malignant 
cholera ; spasmodic cholera. 

Definition. An acute, specific, infectious disease, epidemic in the 
majority of, although endemic in other, localities ; characterized by 
the transudation of serum into the stomach and intestinal canal, and 
violent purging of a peculiar, rice-water-like fluid, the persistent vomit- 
ing of a similar material, severe muscular cramps, and a condition of 
prostration, followed by collapse and death, or of a reaction from the 
collapse and the development of the typhoid state {cholera typhoid}. 

Causes. A specific poison, the "comma bacillus" of Koch. 
Cholera is but feebly contagious, in the usual acceptation of that 
word, but it is unquestionably infectious. 

The evidence seems conclusive that the cholera stools are the main, 
if not the only, channel of infection, and that the great cause of the 
propagation of cholera is the contamination, with the cholera stools, 
of the water used for drinking purposes. Milk may also be the 
vehicle by which it spreads. It is claimed that the bacillus is inert 
in the intestinal canal unless the individual is in the " receptive 
state" — that is, a condition of intestinal catarrh, such as results from 
eating unripe fruit, beer and spirit drinking, and indigestible food. 
It is also determined that the bacilli are destroyed by acids, and that 
if the stomach be normal, cholera will not result. "With pure 
water, pure air, pure soil, and pure habits, cholera need not be 
feared." (Hart.) 

Little, if any, danger exists from being in the presence of the 
affected, although the emanations from the cholera excreta in the 
atmosphere may generate the disease if swallowed or inhaled. The 
dead bodies of cholera subjects apparently possess slight infective 
property, "the bacteria of composition" probably destroying the 
cholera germs. One attack does not afford protection against another. 



240 PRACTICE OF MEDICINE. 

The period of incubation is short, under a week, usually. 

Pathological Anatomy. This is, as yet, far from satisfactory. 
The morbid appearances in the majority of cases of death from chol- 
era may be thus summarized. The temperature generally rises after 
death, the body remaining warm for a considerable time. Rigor 
mortis rapidly ensues, the muscular contractions being often so pow- 
erful as to displace and distort the limbs. The skin is mottled and 
the body greatly shrunken. The blood is darker in color, thick, 
viscid, feebly coagulable, and slightly acid. The arteries are quite 
empty of blood; the veins, on the other hand, are distended. The 
organs are, as a rule, pale and shrunken. 

The stomach and intestinal mucous membranes are congested, and 
present evidence of extravasation and ecchymoses, or are bleached 
and pale. The stomach and intestines usually contain a quantity of 
whey-like material, having an alkaline reaction, as well as quantities 
of cast-off epithelium and the bacillus. It is thought by many that 
the stripping-off of the epithelium is a post-mortem phenomenon. 
The Peyer's solitary and Brunner's glands are usually enlarged and 
prominent, and occasionally evidences of ulceration are apparent in 
the solitary glands, and sections placed under the microscope show 
the "comma bacillus." The villi of the mucous membrane, as well 
as the epithelium of the small intestines, are stripped off, leaving the 
basement membrane, for the most part, exposed. The liver is more 
or less advanced in fatty degeneration, presenting a somewhat mot- 
tled, yellowish discoloration. The kidneys are congested, the epi- 
thelium of the tubules granular, and detached from the basement 
membrane, blocking up the tubes. Prof. Bartholow observed, in all 
of his autopsies, "considerable hyperemia and dilatation of the ves- 
sels of the medulla oblongata. The constancy of this lesion would 
seem to indicate a relationship between congestion of the medulla 
and the cramps." 

Symptoms. In accordance with the law of epidemic infectious 
diseases, the onset, course, and character of the symptoms vary in 
different cases and at different periods in the same epidemic. 

The disease may either set in suddenly in a patient previously in 
good health, or it may follow an attack of rather severe and persistent 
diarrhoea, with pain, nausea, vomiting, and depression. Such cases 
are termed Cholerine, the stools of which are infectious. 

In a typical case there are three stages: first, diarrhoea; second, 
prostration ; third, collapse, or, in favorable cases, reaction. 



ACUTE GENERAL DISEASES. 241 

First Stage. Begins with chilliness, excessive thirst, coated tongue, 
unpleasant taste in the mouth, slight abdominal pain, and three or 
four copious, watery, yet faecal stools during the day, and a decided 
feeling of weakness, the stools rapidly becoming whey-like, easily 
voided, but with force and only slight pain. 

Second Stage. The stools rapidly increase in number, are voided 
with a rushing force, and consist of many quarts of grayish, or whitish, 
rice-water-like fluid, accompanied with forcible vomiting, first of the 
contents of the stomach, mixed with more or less bilious matter, 
afterward of the peculiar rice-water-like material ; thirst becomes 
most intense, increasing or diminishing with the variations in the 
number of the vomiting and stools ; severe muscular cramps soon 
follow, most severe in the calves, although occurring in all parts of 
the body. 

Third Stage. The stools, vomiting, and cramps continue. The 
appearance of the patient becomes frightful; the eyes are sunken 
and surrounded by blackened rings, the nose pinched and pointed, 
the cheeks hollow, and the lips blue (facies cholerica) ; the surface 
cold and moistened with a sticky perspiration ; the skin of the hands 
and fingers has the sodden appearance of the " washerwoman who 
has washed all day," and if picked up in folds, the fold but slowly 
disappears. The temperature rapidly falls, the pulse becomes small 
and compressible, barely perceptible at the wrist, and the heart-beats 
are scarcely recognizable. The voice is weak, husky, and sepulchral 
(vox cholerica), the tongue is like ice, the breath is cold and icy, the 
urine markedly diminished and albuminous. The mind is clear, 
but most patients are apathetic and indifferent to their danger. This, 
the algid state of cholera, or cholera asphyxia, usually terminates in 
death in from three to twelve, twenty-four, or forty-eight hours, but 
reaction may be established. 

Stage of Reaction. The temperature of the body rises, the pulse 
gradually becomes fuller and stronger, the countenance becomes 
brighter, the stools less frequent and more faecal, the vomiting de- 
creases, the thirst lessens ; the urine increases in amount, but con- 
tinues albuminous, the patient entering a slow convalescence, or 
typhoid symptoms develop, the so-called cholera typhoid, which pro- 
longs the recovery for several weeks. 

Convalescence is often prolonged and complicated by the develop- 
ment of severe bed-sores, boils, bronchitis, pneumonia or parotitis. 
21 



242 PRACTICE OF MEDICINE. 

Sequelae. Suppuration of the parotid gland ; painful tetanic con- 
traction of the flexor muscles of the limbs ; abscesses or ulcers of the 
limbs ; profuse sweats ; roseola, erythema, urticaria, and rarely vesicu- 
lar eruptions. 

Diagnosis. The epidemic character and rapid spreading and 
great mortality of the affection prevents its being mistaken for any 
other disease, although isolated cases are often confounded with 
cholerine or with cholera morbus, the points of distinction being few, 
unless the "comma bacillus" only be found in the stools of true 
cholera. 

Prognosis. Very unfavorable, the mortality ranging from twenty 
to eighty per cent.; The last epidemic in this country was much 
milder than former ones. The prognosis is controlled by the general 
condition of the patient, the age, habits, and the development of the 
algid state; the prognosis being more favorable in those cases which 
develop gradually than in those in which it reaches its acme at a 
single bound ; the very young or very old, those addicted to the 
various excesses and surrounded by unfavorable hygienic conditions, 
are more apt to perish than are others. 

Treatment. The success depends, to a great extent, upon its 
prompt and early treatment, for experience amply attests that the 
arrest of the disease in the diarrhceal stage is comparatively easy, 
and in the stage of collapse its cure is altogether an exceptional 
occurrence; therefore, during the prevalence of cholera the mildest 
cases of diarrhoea ought to receive prompt treatment, for many cases 
have their beginning as a mild diarrhoea. 

It must not be overlooked that intelligent nursing and regimen are 
equally as important as medical treatment. 

The patient should be put to bed at once, and all food withheld for 
a time at least. Small pellets of ice may be allowed instead of water. 

" Of all the remedies proposed for the arrest of the diarrhoea, not 
one has done so much good as sulphuric acid. It is usual, and 
generally best, to combine some opium with it (R. Acid, sulphuric, 
aromat., f^v (20 Cc); tinct. opii deodorat., f^iij (12 Cc). M. SiG. — 
Ten to twenty drops every hour or two in sufficient water)." (Bar- 
tholow.) 

Large doses of bismuth should be of value in this early stage, but 
opium is particularly indicated, preferably in the form of morphinae 
sulphas, hypodermically. During the epidemics of iSo^-'o^, good re- 



ACUTE GENERAL DISEASES. 243 

suits were reported from the internal use of hydrogen peroxide, f^ij 
(60 Cc), with aqua destillata, f^viij (237 Cc), in cupful doses every 
two hours. Salol and plumbi acetas are of value for the early 
diarrhoea. 

Ziemssen says : " Calomel has the first place of all drugs which 
have been recommended in the prodromal stage. Begin with two or 
three doses of gr. vij (0.45 Gm.), followed with small doses — gr. % 
(0.048 Gm.) — every two hours." 

It is now generally admitted that as the first symptoms of cholera 
are those of intestinal catarrh, direct medication ought to be of the 
greatest service. This is done by enteroclysis or irrigation of the 
canal with large amounts, from one to three gallons twice daily, of 
hot soaped water, hot four per cent, solutions of hydrogen peroxide, or 
weak solutions of tannin, or hot one per cent, solutions of common salt. 

The enteroclysis is accomplished by means of a soft rubber tube, 
one metre in length and of suitable size, to be introduced into the 
rectum, in front of the promontory of the sacrum, into and up through 
the sigmoid flexure and into the descending colon. This tube, which 
is connected with a reservoir, should not be too small nor too large, 
in order to facilitate its introduction through the folds of the sigmoid 
portion of the lower bowel. 

In fact, the greatest difficulty to be encountered is to successfully 
pass the tube in front of the promontory of the sacrum, and enter it 
into the sigmoid flexure. The tube should be of proper firmness to 
prevent it from bending or buckling upon itself when the end (which 
in all cases should be rounded) comes in contact with the obstructing 
folds of the intestine. 

For the distressing vomiting, lavage of stomach with hydrogen 
peroxide, f^ij (60 Cc.) to two or three pints of hot water, or iced chain- 
pagne, cocaine, or acidum hydrocyanicum may sometimes give relief. 

Locally, either mustard applications to the abdomen or the constant 
use of rubber bags filled with boiling water. 

For the cramps, hot water in bottles, hot irons or bricks applied 
over painful parts, or an ointment of chloroform or chloral, chloro- 
form or ether inhalations, or the use of the following hypodermic 
solution, strongly recommended by Prof. Bartholow : 

ft. Chloral, giij 12. Gm. 

Morphinse sulph. , gr. iv .26 Gm. 

Aquae lauro-cerasi, f 3 j 30. Cc. M. 

Sig. — Fifteen to thirty minims each injection. 



244 PRACTICE OF MEDICINE. 

For the collapse, heat to the surface and the free use of stimulants, 
or spiritus frume?iti, or spiritus vini gallici, hypodermically, also the 
hot bath, also hypodermatoclysis and the intravenous injection of 
saline fluids and hypodermic injections of strychninae sulphas, gr. -^ 
(0.003 Gm.). Heat is of the greatest value in all stages of cholera, 
both externally as very hot baths (hot air or hot water), and hot rectal 
injections. 

If reaction occur, treat indications as they arise, and use tonics, 
such &sferrwn, quinina, and arsenicutn. 

All the discharges from the patient should be thoroughly disinfected 
as soon as voided, and the stools and vomited material buried. 



DISEASES OF THE RESPIRATORY 
SYSTEM. 



PHYSICAL DIAGNOSIS. 

Physical Diagnosis is the art of discriminating disease by 
means of the eye, the ear, and the touch. 

The signs thus ascertained are connected with changes or altera- 
tions in the form, density, or condition of the structures within, and 
are known as physical signs. 

" Physical signs are, then, the exponents of physical conditions, and 
of nothing more." (Da Costa.) 

The methods employed in the physical exploration of the chest, 
are: I, Inspection; II, Palpation; III, Mensuration; IV, 
Percussion; V, Auscultation; VI, Succussion. 

Percussion and auscultation, dealing with sounds, are of the great- 
est value clinically. 

For the purpose of physical exploration, the chest is mapped off 
into regions or divisions, as follows : 

ANTERIORLY. 

First. — Supra-clavicular, Lying above the upper edge of the 
clavicle, usually about an inch in extent. 



DISEASES OF THE RESPIRATORY SYSTEM. 245 

Second. — Clavicular, Corresponding to the inner two-thirds of the 
clavicle. 

Third. — Infra-clavicular ; From the clavicle to the lower border of 
the third rib. 

Fourth. — Mammary, Between the third and sixth ribs. 

Fifth. — Infra-inammary , Downward from the sixth rib. 

LATERALLY. 

First. — Axillary, That portion above the sixth rib. 
Second. — Infra-axillary, That portion below the sixth rib. 

POSTERIORLY. 

First. — Supra-scapular, That portion above the scapula. 
Second. — Scapular, That portion covered by the scapula. 
Third. — Inter-scapular, That portion between the scapulae. 
Fourth. — Infra-scapular, That portion below the angle of the 
scapula. 

INSPECTION. 

Inspection signifies "the act of looking." Views of the chest 
should be taken from the sides and behind as well as from the front, 
for which purpose a good light should be obtained, and the patient 
be placed in as easy and comfortable a position as is possible. 

Inspection reveals the form, size, color, and movements of the chest, 
as well as the condition of the superficial parts. 

In health the sides of the chest are for the most part symmetrical 
in form, size, color, and movements, both sides rising equally during 
the act of inspiration, and falling equally during the act of expira- 
tion. During the act of inspiration the intercostal spaces in the 
lower two-thirds of the chest become more hollow, as also do the 
supra-clavicular fossae. 

Inspiration is almost entirely the result of muscular action ; expira- 
tion, on the other hand, is chiefly due to' the elasticity of the lungs 
and chest walls, aided somewhat in forced respiration by muscular 
action. The movement of inspiration by inspection is of longer 
duration than that of expiration, and the pause between the acts but 
momentary. 

The respiratory movement is visible over the whole thorax, although 



246 PRACTICE OF MEDICINE. 

in males and in children it is most distinct at the lower portion [in- 
ferior costal breathing), while in the female it is most distinct at the 
upper portion of the chest {superior costal breathing). 



PALPATION. 

By palpation is meant the application of the palmar surfaces of 
the hands and fingers to the chest, by means of which are appre- 
ciated impressions which are capable of being conveyed by the 
sense of touch. 

The objects of palpation are : 

First. — To give more accurate information of what is revealed 
by inspection. 

Second. — To locate spots of soreness, the density and condition of 
tumors, if any be present; the state of the chest walls, the frequency 
of the breathing, and the action of the heart. 

Third. — To determine the existence and character of the various 
kinds of fremitus (vibrations). 

By fremitus is understood certain tactile impressions or vibrations 
conveyed to the surface of the chest, which are classed and produced 
as follows : 

First. — Vocal fremitus, produced by the act of speaking or crying. 

Second. — Tussive fremitus, produced by the act of coughing ; of 
value especially when the voice is very weak. 

Third. — Bronchial fremitus, produced by the passage of air 
through mucus, blood, or pus, in the bronchial tubes, during the act 
of respiration. 

Fourth. — Friction fremitus, produced by the rubbing together of 
the roughened surfaces of the pleura. 

When the normal chest vibrates lightly, it is termed the normal 
vocal fremitus. . 

The vocal fremitus is more distinct upon the right side toward the 
apex. 

If the lung be consolidated (denser), the vibration is greater and 
more easily distinguished, — the vocal fremitus is increased. 

In feeble persons, or when any cause interferes with the trans- 
mission of the vibrations, the vocal fremitus is diminished or absent. 






DISEASES OF THE RESPIRATORY SYSTEM. 247 



MENSURATION. 

Mensuration, or measurement of the chest, is of little practical 
importance, and hence seldom performed. The only measurement 
likely to be required is the circular or circumferential, in different 
parts of the chest, which is performed with either an ordinary gradu- 
ated tape measure or a double tape measure, made by uniting two 
tapes in such a manner that they start in opposite directions from the 
same point at the mid-spinal line. The tapes drawn around each 
side until they meet at the id-sternal line, on a line immediately 
above the nipple, or on the level of the sixth rib near its attachment 
to the cartilage, — the sixth costo-sternal joint, — the patient first being 
directed to effect a complete expiration, the number of inches noted, 
and then to take a deep inspiration, the increase in inches noted, the 
difference between the two giving a rough estimate of the capacity 
of the lungs. 

In right-handed persons the right side is usually one-half to three- 
fourths of an inch larger than the left ; if larger than this, it is usually 
the result of some abnormal condition. 

In well-developed men the chest measures at the upper part about 
thirty-three to thirty-five inches during expiration, and is increased 
fully three inches upon inspiration. 



PERCUSSION. 

Percussion, or " The act of striking," to ascertain the composition 
of structures, affords signs and information of great value in diagnosis. 

There are two methods employed, immediate and mediate. 

Immediate, or direct percussion, is performed by striking the thorax 
directly with the points of the fingers or the palmar surface of the 
hand. This method of percussion has been generally abandoned, as 
it does not enable the physician to distinguish, with sufficient correct- 
ness, between the various shades of difference in the pitch or quality 
of percussion sounds. 

Mediate, or indirect percussion, may be practised in three different 
ways, to wit : 

First. — With the finger of one hand interposed between the body 
percussed and the percussing finger. 



248 PRACTICE OF MEDICINE. 

Second. — With the finger acting as a pleximeter and the percussion 
hammer. 

Third. — With the percussion hammer and the pleximeter. 

The first of these modes affords the most correct and ready infor- 
mation regarding the resistance of the parts percussed. The skillful 
use of the fingers is more difficult to acquire than that of the plexi- 
meter and hammer; but if the examiner has acquired sufficient skill 
in its performance, an absolutely accurate result may be obtained. 
" He who is skilled in digital percussion will be able to percuss equally 
well with the hammer, the inverse of which does not always hold 
good." In addition to being proficient in the technical modus oper- 
andi, it is necessary to possess a sensitive ear, educated to distinguish 
between the various shades of the sounds. 

When the fingers are employed, it is a matter of choice whether one 
or more fingers are used as the pleximeter. Usually the last phalanx 
of the first or second fingers of the left hand are used, the other fingers 
being raised from the chest, so as not to interfere with the sound 
vibrations ; they should be applied firmly and evenly to the surface, 
thus preventing the slipping of the soft parts, and also to determine 
the resistance of the chest walls when the blow is given. The rounded 
ends of the first and second fingers of the right hand are used as a 
hammer, striking the pleximeter fingers in such a manner that the 
nails shall not touch the skin of the underlying fingers. The force 
employed varies in different regions, but usually, for the chest, should 
be only of moderate degree. Forcible percussion is of use only when 
the sound of deep-seated organs is desired. 

The stroke should be made perpendicularly to the surface, and not 
slanting, as is too often done. The whole movement should proceed 
only from the wrist-joint, and ought not to be too rapid or unequal, 
or of great force, the fingers being rapidly withdrawn, so as not to 
interfere with the vibrations. 

The objects of percussion are to elicit certain sounds, and the 
amount of resistance or elasticity of the organs percussed. 

The main sounds elicited by percussion are the dull, clear, and 
ty?npanitic. Familiarity with the intensity, character, and pitch of 
each of these sounds is essential. 

When percussing the healthy chest, the sound obtained is termed 
the normal pulmonary resonance. It is of variable intensity, depend- 
ing upon the force of the stroke employed and the amount of adipose 



DISEASES OF THE RESPIRATORY SYSTEM. 249 

and muscular tissues covering the thorax, and the tension of the chest 
walls. 

There is no exact standard of the normal pulmonary or vesicular 
resonance, but if the two sides of the chest are compared, the normal 
standard of each person is obtained. 

The character is termed pulmonary or clear, as characteristic of 
the healthy chest wall. The pitch is always relatively low. 

The sounds elicited by percussing a healthy chest are not, however, 
alike over all its parts. 

Anteriorly, the portion of lung above the clavicle yields a sound 
which becomes somewhat tympanitic as the trachea is approached. 

Over the clavicle the sound is clear and pulmonary at the centre of 
the bone, but at the scapular extremity it is duller, and toward the 
sternum it becomes somewhat tympanitic. 

At the infra clavicular region the resonance is clear and distinct, 
but little resistance being offered to the percussing finger, and the 
sound elicited may be taken as the type of the pulmonary resonance. 
In this region, however, a slight disparity exists between the two sides; 
on the right side the sound is less clear, shorter, and of a higher pitch 
than on the left side. 

In the mammary region of the right side the resonance of the lung 
is not so clear, the sound being modified by the size of the mamma 
and the upper border of the liver. On the left side the heart deadens 
the sound from the fourth to the sixth rib, and, in a transverse direc- 
tion, from the sternum to the left nipple. This dull sound in the left 
mammary region is lessened in extent during full inspiration, and in 
emphysema, when the lung more completely covers the heart. 

In the infra-mammary region on the right side the percussion note 
is dull, except during the act of complete inspiration, when the liver 
is displaced downward by the inflated lung. In the left infra-mam- 
mary region the sound consists of a mixture of the dull sound of the 
heart and spleen and of the clear sound of the lung, together with 
the tympanitic sound of the stomach. 

Over the upper part of the sternum — above the third rib — the sound 
is slightly tympanitic. Below the third rib, over the sternum, the 
sound is dull, due to the presence of the heart and liver. 

The position exercises some influence on the results of percussion. 
More accurate results are obtained when the patient is standing or 
sitting than when recumbent. While the front of the chest is per- 

22 



250 - PRACTICE OF MEDICINE. 

cussed, the arms should hang loosely by the sides ; the hands may 
be clasped across the top of the head during the percussion of the 
axillary region ; during the examination of the back the head must 
be bent forward and the arms tightly crossed in front. 

On the posterior surface of the chest the sound also varies accord- 
ing to the part percussed. 

Over the scapula the sound is duller than between these bones or 
below their inferior angles. 

Over the infra- scapular region a clear sound is obtained as far as 
the lower border of the tenth rib on the right side, where the dullness 
of the liver begins. On the left side, below the angle of the scapula, 
the percussion sound is tympanitic if the intestines are distended, or 
it may be slightly dull if the spleen is enlarged. 

In the axillary region the sound is clear and distinct on each side. 

In the infra-axillary region of the right side the sound is duller, 
owing to the presence of the liver ; at the corresponding situation on 
the left side the sound is clear or tympanitic ', from the distention 
of the stomach, and at the ninth or tenth rib of the left axillary 
region dullness and the sense of resistance mark the location of the 
spleen. 

The sounds obtained by percussion of the unhealthy or abnormal 
chest are as follows : 

First. — Hyper-resonance, or an increase of the normal pulmonary 
resonance, is due to the relative increase in the proportion of air to 
the solid tissues of the lung, provided the tension of the chest walls 
be not altered, occurring in emphysema of the lungs, atrophy of the 
lungs, or consolidation of the opposing lung. 

Second. — Dullness or an absence of resonance, due to the relative 
increase of solid tissues in proportion to the amount of air, as seen in 
the different stages of phthisis, in pneumonia, pleural effusion, and 
hydrothorax. 

The pitch is increased or heightened in proportion to the diminu- 
tion of the amount of the air and the increase of the solids. 

If there be entire want of resonance, the percussion note is said to 
be flat ; if there is a slight decrease in the resonance of the part, the 
note is said to be impaired. 

The sense of resistance is greater, the more marked the consolida- 
tion of the lungs and the greater the tension of the chest walls. 

Third. — Tympanitic, or the drum-like percussion note, is a non- 



DISEASES OF THE RESPIRATORY SYSTEM. 251 

vesicular sound having the character elicited by percussing over the 
normal intestines ; wherever heard it indicates the presence of air in 
conditions similar to that of the intestines, to wit : inclosed in walls 
which are yielding, but neither tense nor very thick. 

When elicited over the chest it may be due to the transmitted 
sound of the distended stomach or colon. It is obtained over the 
chest in pneumothorax, in moderate pleural effusions above the level 
of the liquid, over the seat of cavities in the pulmonary tissue, and 
in oedema of the lungs. 

The tympanitic percussion note differs from the normal pulmonary 
resonance in being more ringing in character and of a higher pitch. 

The amphoric or metallic sound is in reality a concentrated tym- 
panitic sound of high pitch, and denotes a large cavity with firm, 
but yet elastic, walls. 

The cracked-pot or cracked-metal sound is another variety of the 
tympanitic sound. The condition most frequently producing this 
sound is a cavity in the lung tissue, communicating with a bronchial 
tube. It requires for its development a strong, quick blow of the 
percussing finger, with the patient's mouth open. 

RESPIRATORY PERCUSSION. 

The percussion sound will vary greatly with the respiratory move- 
ments. If a full inspiration be taken and percussion performed, then 
a full expiration taken and percussion performed, and then the chest 
percussed during the normal respiration, slight changes in the char- 
acter and pitch of the note are obtained, which otherwise would 
escape detection. Prof. Da Costa has designated this method, respi- 
ratory percussion. 

AUSCULTATORY PERCUSSION. 

This method consists in listening, with a stethoscope applied to the 
thorax, to the sounds elicited by percussion. " It is a serviceable 
means of determining with accuracy the boundaries of various 
organs, as those of the lungs or heart, or of the liver or spleen, and 
yields particularly exact results when carried out with the double 
stethoscope." 



252 PRACTICE OF MEDICINE. 



AUSCULTATION. 

Auscultation, or listening to the sounds produced within the 
chest during the act of respiration, coughing, or speaking, furnishes 
the most reliable means of studying the condition of the lungs and 
heart, and is, therefore, the most valuable method of discriminating 
between the various conditions which may affect the lungs and heart. 

Auscultation is either immediate or mediate. 

It is immediate when the ear is applied directly to the chest, which 
may be either denuded or thinly covered. 

It is mediate when the sounds are conducted to the ear by means 
of a tubular instrument, termed a stethoscope. 

For ordinary purposes, immediate or direct auscultation is suffi- 
cient, but when it is desirable to analyze circumscribed sounds, as in 
diseases of the heart, or where the patient objects to this method, on 
the score of delicacy, or the auscultator objects, on account of the 
uncleanliness of the person examined, the stethoscope is to be pre- 
ferred. Moreover, there are certain parts of the chest which can 
only be explored satisfactorily by the aid of a stethoscope, which 
instrument has the additional advantage of intensifying the sound. 

In auscultation, the following rules, formulated by Prof. Da Costa, 
should be observed : 

" i. Place yourself and your patient in a position which is the least 
constrained and permits of the most accurate application of the ear 
or stethoscope to the surface. Above all, avoid stooping, or having 
the head too low. 

" 2. Let the chest be bare, or, what is better, covered only with a 
towel or thin shirt. 

" 3. If a stethoscope be employed, apply closely to the surface, but 
abstain from pressing with it. This may be obviated by steadying 
the instrument, immediately above its expanded extremity, between 
the thumb and the index finger. 

"4. Examine repeatedly the different portions of the chest, and 
compare them with one another while the patient is breathing 
quietly. Making him cough or draw a full breath is, at times, of 
service : especially the former, when he does not know how to 
breathe." 



DISEASES OF THE RESPIRATORY SYSTEM. 253 

SOUNDS IN HEALTH. 

If the ear be applied over the larynx or trachea of a healthy per- 
son, a sound is heard with both the act of inspiration and expiration. 
Its intensity is variable, its pitch high, and its quality tubjilar (to wit: 
a current of air passing through a tube — the larynx or trachea). The 
duration of the sound during inspiration being somewhat longer than 
during expiration. A short pause follows the act of expiration. 

This sound is termed the normal laryiigeal respiration, and is 
identical in character, duration, and pitch with an important morbid 
sound, termed bronchial respiration. 

The sound heard by placing the ear over the lung tissue is differ- 
ent ; it is produced in the very finest bronchial tubes and air cells by 
their expansion and contraction, and is termed the normal vesicular 
murmur. 

The inspiratory portion of the sound is of variable intensity, its 
pitch is low, its quality soft and breezy, designated vesicular ; its 
duration is during the entire act of inspiration. 

The expiratory portion of the sound 'is not always perceptible ; it is 
of feeble intensity, very low pitch, its character soft and blowing, and 
its duration much less than the act of inspiration. 

It is to be remembered, however, that the vesicular murmur will be 
found to vary in the different regions on the same side, and in corre- 
sponding regions on the two sides of the chest. These variations 
within the range of health are especially important, and should be 
memorized. 

Infra-clavicular Region. — The vesicular murmur in this region on 
either side is much more distinct than over any other part of the 
chest. 

On the left side the inspiratory sound is of greater intensity, of 
lower pitch, and more distinctly vesicular in quality than that heard 
upon the right side. On the right side the expiratory sound is nearly 
or quite the same in length as the inspiratory sound, and is higher in 
pitch and more tubiclar'm. quality than the expiratory sound upon the 
left side. 

Supra-scapular Region. — Owing to the small number of air vesicles 
and the large number of bronchial tubes, and their nearness to the 
surface, the respiratory murmur has an intense, high-pitched, tubular 
and expiratory quality. 



254 PRACTICE OF MEDICINE. 

Scapular Region. — Compared with the infra-clavicular region, the 
respiratory murmur heard over the scapulae on either side is more 
feeble, and the vesicular quality less marked. 

Inter-scapular Region. — The murmur in this region differs from the 
normal laryngeal breathing only in intensity and duration. 

Infra-scapular Region. — The murmur in this region very closely 
resembles that heard in the left infra-clavicular region. 

Mammary and Infra-ma7nmary Regions. — The murmur in these 
regions differs from that heard in the infra-clavicular region, in being 
of less intensity. 

Axillary and Infra- axillary Regions. — The respiratory sound in 
the axillary regions is as intense as in any portion of the chest. In 
the infra-axillary regions the intensity is less and the pitch lower. 

VOICE IN HEALTH. 

If the ear be applied over the larynx or trachea of a healthy per- 
son, and he be directed to count " twenty-one, twenty-two, twenty- 
three," in a uniform tone and with moderate force, there is perceived 
a strong resonance, with a sensation of concussion or shock, and a 
sense of vibration, thrill, or fremitus, the voice seeming to be concen- 
trated and near the ear. Often the articulated words are distinctly 
transmitted (laryngophony). 

The sounds thus heard are termed the normal laryngeal resonance. 

If the ear or stethoscope be applied over the third rib anteriorly, on 
either side of the chest of a healthy person, and he be directed to 
count "twenty-one, twenty-two, twenty-three," in a uniform tone, 
with moderate force, a confused distant hum is perceived of variable 
intensity, accompanied with more or less vibration, thrill, or fremitus, 
most distinct in adults, but notably weaker in women than in men. 

This sound is termed the normal vocal resonance. 

If the ear or stethoscope be applied over the third rib anteriorly, of 
a healthy person, and he be directed to whisper, in a uniform man- 
ner, the words " twenty-one, twenty-two, twenty-three," there is heard 
a sound corresponding closely in character to the sound of expiration 
over the same region during the act of forced respiration; or, in other 
words, a feeble, low-pitched, blowing sound. 

This sound is termed the normal bronchial whisper, and is produced 
by the movement of the air in the bronchial tubes during the act of 
respiration. 



DISEASES OF THE RESPIRATORY SYSTEM. 255 

SOUNDS IN DISEASE. 

The vesicular murmur may undergo, in disease, changes in its in- 
tensity, its rhythm, and in its character. 

The intensity of the respiratory murmur may be : 
i . Exaggerated or increased. 

2. Diminished ox feeble. 

3. Absent or suppressed. 

Exaggerated respiration differs from the normal vesicular 
respiration only in an increase in the intensity of the respiratory 
sounds. When general over one lung, it will usually indicate deficient 
action of other parts. In this manner an effusion compressing the 
lung, one-sided deposits, obstruction of the bronchial tubes by secre- 
tion, or inflammation of the lung structure, necessitate a supple- 
mentary respiration in a healthy portion of the same lung or the lung 
upon the opposite side. From its resemblance to the loud, strong, 
quick respiration of young children, it has been termed puerile res- 
piration. 

Exaggerated respiration is, therefore, to be regarded as indirect 
evidence of disease in some portion of the pulmonary tissue. 

Diminished respiration, called also senile respiration, as being 
characteristic of old age, is characterized by diminished intensity and 
duration of the sound. In the large majority of instances the inspi- 
ration suffers the greatest, the expiratory sound not diminishing in the 
same proportion. In asthma, emphysema, diseases of the larynx and 
bronchial tubes, pleuritic pain, rheumatism or paralysis of the chest 
walls, or in thickening of the pleural membrane, we observe super- 
ficial or diminished respiration. When one side of the chest is par- 
tially filled with fluid, we may hear a deep-seated but feeble breath 
sound. 

Absent or suppressed respiration occurs whenever the action 
of the lung is suspended ; this may be from external pressure, as when 
the lung is compressed by the presence of fluid or air in the pleural 
cavity, or when complete obstruction of the bronchial tubes prevents 
the air from either entering or escaping from the lungs. 

The rhythm of the respiratory murmur may be : 

1 . Interrupted or jerky. 

2. The interval between inspiration a?id expiration prolonged. 

3. Expiration prolonged. 



256 PRACTICE OF MEDICINE. 

In health the inspiratory and expiratory sounds are even and con- 
tinuous, with a short interval between each act ; this may be altered 
in disease, and both sounds, especially the inspiratory, have an inter- 
rupted or jerky character, termed " cog-wheel respiration." 

This jerky breathing* is noted in some spasmodic affections of 
the air tubes, in hysteria, the earliest stages of pleurisy, pleurodynia, 
and the early stages of pulmonary phthisis. It is most frequently 
associated with phthisis, due probably to the adhering to the walls of 
the finer bronchial tubes of tough mucus, which obstructs the free 
entrance and exit of the air; it is usually most notable under the 
clavicles. 

The interval bet-ween inspiration and expiration may 
be prolonged, instead of these two sounds closely succeeding each 
other. When this occurs the inspiratory sound may be shortened, 
or the expiratory sound may be delayed in its commencement. If 
the inspiratory sound is shortened, it is the result of consolidation 
of the lungs ; if the expiratory sound is delayed, it is the result of 
lessened elasticity of the lung structure, and is most commonly asso- 
ciated with emphysema. 

Prolonged expiration denotes that the air is obstructed in its 
exit from the lungs. It may be the result of diminished elasticity, 
the result of emphysema, or from the deposit of tubercles, which 
impair the contractile power of the lungs. If the former, it is asso- 
ciated with clearness on percussion ; if the latter, however, with 
impaired resonance on percussion. When prolonged expiration is 
detected at the apex of the lung, and is associated with impairment 
of the normal pulmonary resonance, it is for the most part the result 
of a tubercular deposit. 

The quality of the respiratory murmur may be : 

1. Harsh, termed vesiculobronchial respiration. 

2. Bronchial. 

3. Cavernous. 

4. Amphoric. 

Harsh respiration, or, as it is termed by Prof. Da Costa, vesiculo- 
bronchial respiration, is that variety in which both the inspiratory and 
expiratory sounds have lost their natural softness. It generally indi- 
cates more or less consolidation of lung tissue. In normal vesicular 
respiration the sounds produced by the air expanding the air cells and 
finer bronchial tubes obscures the sound produced by the passage of 



DISEASES OF THE RESPIRATORY SYSTEM. 257 

air through the larger bronchial tubes, the healthy lung being an 
imperfect conductor of sound, so that as soon as any portion of the 
lung becomes consolidated the vesicular element of the respiratory 
sound is diminished, the bronchial element becoming prominent. 
Harsh respiration is, then, a union of the vesicular and bronchial 
sounds, being a vesicular sound mixed with some of the qualities of 
a bronchial sound, the expiration being prolonged and tubular in 
character. It is present when the bronchial mucous membrane is 
swollen, as in the earlier stages of bronchitis, also in the earlier stages 
of phthisis and pneumonia. 

Bronchial respiration is characterized by an entire absence of 
all the vesicular quality. Inspiration is of high pitch and tubular in 
character; expiration still higher in pitch, of greater intensity, pro- 
longed and tubular in quality ; the two sounds being separated by a 
brief interval. 

The bronchial respiration encountered in disease closely resembles 
that heard in health over the larynx or trachea. Whenever bronchial 
respiration is present where, in health, the normal vesicular murmur 
should be heard, it indicates consolidation of the lung structure. 

Cavernous respiration is a variety of the bronchial respiration, 
at least so far as the quality of the sound is concerned. It is essen- 
tially a blowing sound, yet not always heard during both the acts of 
inspiration and expiration, being often only perceptible in the one, 
and in the other mixed with gurgling sounds. Its pitch is lower than 
that of ordinary bronchial respiration, and its character is hollow. 

For its production there must be a cavity of considerable size in 
the lung substance, not filled with fluid, near the surface of the chest 
walls, communicating with a bronchial tube. It is met with most 
commonly in the last stages of pulmonary consumption, although 
hollow spaces of any kind, from abscess or dilatation of the bronchial 
tubes, occasion it. 

Amphoric respiration is a blowing respiration, having a musi- 
cal or metallic quality. It is a variety of bronchial respiration pro- 
duced in a large cavity with firm walls, permitting the reflection of 
the sound. An imitation of this sound, though only an imperfect 
one, is produced by blowing over the mouth of an empty bottle. 
The amphoric character is present with both the acts of inspiration 
and expiration. 

Amphoric or metallic respiration is indicative of a large cavity, not 



258 PRACTICE OF MEDICINE. 

common in phthisis, but much oftener heard at the upper part of a 
lung compressed by fluid and air, as in pneumo-hydrothorax. 



RALES. 

Rales, or, as they are termed, adventitious sounds, because they 
have no analogue in the healthy state, cannot be considered as modi- 
fications of the normal respiration. 

Grouped according to the anatomical situation in which they are 
produced, we have : 

1 . Laryngeal and tracheal rales. 

2. Bronchial rales. 

3. Vesicular rales. 

4. Cavernous rales. 

5. Pleural rales. 

Rales may be divided into two groups, according to their character, 
to wit : dry and moist, and may be audible either during the act of 
inspiration or expiration, or during both. 

Dry rales, for the most part, are produced by the vibration of 
thick fluids which the air cannot break up, and which, therefore, 
temporarily lessens the calibre of the bronchial tubes. When this 
narrowing exists in the smaller bronchial tubes the resulting sound is 
high-pitched or the rale is said to be sibilant or whistling ; when the 
narrowing exists in the larger bronchial tubes, the rale is low-pitched, 
more musical in character, or sonorous. 

Dry rales are particularly prone to be dislodged by coughing, and 
when they are uninfluenced by the acts of breathing and coughing, 
they do not depend upon the presence of secretions, but upon the 
narrowing of the air tubes from the pressure of tumors, or from a 
thickened fold of mucous membrane, or from a spasmodic contrac- 
tion of the air tubes. 

Moist rales are those produced by the air passing through thin 
fluids, such as mucus, blood, serum, or pus, during the respiratory 
movements. When the fluid exists in the smaller bronchial tubes, 
the rales are termed small bubbling, mucous, or subcrepitant. When 
the fluid is in the large bronchial tubes, the rales are said to be 
large bubbling or mucous. 

Moist rales are not persistent, but vary in intensity, and shift their 



DISEASES OF THE RESPIRATORY SYSTEM. 259 

position as the air drives the liquid which occasions them before it, 
or during violent attacks of coughing, or after copious expectoration. 

Laryngeal and tracheal rales are those produced within the 
larynx and trachea, and may be either moist or dry. The moist or 
bubbling sounds, produced when mucus or other liquids accumulate 
in this part of the air tubes, frequently occur in the moribund state, 
and are then known as the " death rattles." When not due to this 
condition they denote either insensibility to the presence of liquid, 
as in stupor or coma, or inability to remove liquid by the act of ex- 
pectoration, as in croup or inflammation of these parts in the very 
feeble. 

The dry rales produced within the larynx or trachea are generally 
caused by spasm of the glottis — to wit: laryngismus stridulus, whoop- 
ing cough or croup, or from the presence of a foreign body in the 
part. 

Bronchial rales, resulting from the passage of air through the 
thin liquid, occasion bubbling sounds. When the liquid is present 
in the large-sized bronchial tubes, the rales are said to be large 
bubbling, or large mucous rales, occurring in acute or chronic 
bronchitis. 

When the liquid is in the smaller bronchial tubes, the resulting rale 
is called small bubbling, small mucous, or subcrepitant, also occurring 
in acute or chronic bronchitis. 

Bronchial rales, due to the narrowing of the tube by its spasmodic 
contraction, or to the presence of tough, tenacious mucus, which is put 
into vibration by the passage of the air through the bronchial tubes, are 
termed dry bronchial rales. Frequently they are suggestive of cer- 
tain familiar sounds, such as snoring, cooing, humming, or wheezing, 
or they are often musical tones. When produced in the smaller 
bronchial tubes, they are termed sibilant, or high-pitched rales; 
when produced in the larger bronchial tubes, they are termed 
sonorous or low-pitched rales. They principally occur in the dry 
stage of bronchitis, or during an asthmatic paroxysm. 

The vesicular rale, or, as it is more commonly termed, the 
crepitant rale, is produced within the air vesicles or at the terminal 
portion of the smaller bronchial tubes. 

It is to be distinguished from very fine bubbling sounds, or the sub- 
crepitant rale. " // is a very fine sound, or rather series of very fine 
uniform sounds, occuri'ing in puff's and limited to inspiration." 



260 PRACTICE OF MEDICINE. 

(Da Costa.) It resembles the noise occasioned by throwing salt on the 
fire, or alternately pressing and separating the thumb and finger, 
moistened with a solution of gum arabic, and held near the ear, or 
rubbing together a lock of dry hair near the ear. 

The crepitant rale is produced by the movement of fluid in the 
air cells or in the finest extremities of the bronchial tubes, or by the 
forcing open, during the act of inspiration, of the air cells aggluti- 
nated by exuded lymph. These sounds may be defined as being 
very fine, dry, crackling sounds, heard at the end of inspiration. 
They are usually present in the first stage of pneumonia, but when 
limited to the apices are significant of the incipient stage of phthisis. 

Cavernous rales, or, as they are commonly termed, gurgling 
rales, are produced in a pulmonary cavity of considerable size, 
containing a large amount of liquid communicating freely with a 
bronchial tube. The sound is occasioned by the agitation of the 
liquid within the cavity, and may be compared to the sound pro- 
duced by the boiling of liquid in a flask or large test-tube. The sound 
is sometimes high-pitched or musical, whence it has been termed 
"amphoric gurgling," but it is generally low in pitch. The rale is 
heard almost exclusively during the act of inspiration, and its diag- 
nostic importance relates to the advanced stage of phthisis. 

Pleural rales may be either dry or moist. 

Dry pleural rales, or, as they are more commonly termed, friction 
sounds, are occasioned when the surfaces of the pleura are covered 
with a glutinous substance preventing the unobstructed movements of 
the pleural surfaces upon each other during the respiratory acts, for 
in health these movements occasion no sound whatever. The sounds 
are generally interrupted or irregular, occurring during the act of 
inspiration or expiration, or during both acts. The character of the 
sound is variable, being termed rubbing, grazing, rasping, grating, or 
creaking, according to the intensity of the respiratory acts and the 
amount of exudation. 

They are distinguished by the apparent nearness of the sound to 
the ear, and are usually intensified by firm pressure of the stetho- 
scope upon the chest. When the chest is fixed, especially at the 
lower two-thirds, and the ear applied over the seat of the sound, it 
will be found to have disappeared. The sound is diagnostic of the 
first stage of pleurisy or the pre-adhesive stage of tuberculosis of the 
pleura. 



DISEASES OF THE RESPIRATORY SYSTEM. 261 

Moist friction sounds are produced in the same manner as those 
just mentioned, the exudation being softened in character. This 
sound is frequently confounded with moist bronchial rales, and its 
discrimination is often only positive by a careful study of the symp- 
toms and concomitant signs present. 

Metallic tinkling is a sign of pneumo-hydrothorax with per- 
foration of the lung, and when found, is usually diagnostic of this 
affection, although it occurs rarely in cases of phthisis with a large 
cavity, the physical conditions for its production being similar to those 
in pneumo-hydrothorax — to wit : a space of considerable size contain- 
ing air and liquid, the space communicating with the bronchial tubes. 

It consists of a series of tinkling sounds, of high pitch, silvery or 
metallic in tone, and is very well imitated by dropping a small marble 
into a metallic vase. It occurs irregularly, not being present with 
every act of breathing, and may be produced by forced, when not 
heard during tranquil, breathing. 

Were it not for the location and the absence of concomitant signs, 
it might be confounded with tinkling sounds sometimes produced 
within the stomach and transverse colon ; these latter sounds must be 
kept in mind in ausculting the lower chest area. 



THE VOICE IN DISEASE. 

The normal vocal resonance, as heard over the third rib of 
the chest anteriorly on each side, may have its intensity — 
i . Diminished or absent. 

2. Increased or exaggerated. 

Or its resonance may be of the character of — 

3. Bronchophony. 

4. Pectoriloquy. 

5. A^gophony. 

6. A?nphoric voice. 

The vocal resonance may be diminished or feeble in 
bronchitis with free secretion, pleurisy with effusion, or in complete 
consolidation of the lung structure and the bronchial tubes. 

The vocal resonance is absent in pneumothorax and in 
pleurisy with effusion. 

Exaggerated vocal resonance differs from the normal vocal 



262 PRACTICE OF MEDICINE. 

resonance in a slight increase of its density. It denotes a slight 
degree of solidification of lung tissue, and is chiefly of value in the 
diagnosis of tubercle. 

Bronchophony, or the voice concentrated near the ear, raised 
in pitch and in intensity, denotes complete consolidation of the pul- 
monary tissue in those parts in which the sound is abnormally 
present. 

Pectoriloquy is complete transmission of the voice to the ear, 
the articulated words being distinctly recognized. It has a close 
resemblance to the resonance heard over the larynx in health. Its 
presence indicates either a pulmonary cavity or more complete con- 
solidation — in other words, an exaggerated bronchophony. 

.^jgophony is a modification of bronchophony, consisting in 
tremulousness of the voice, its character nasal or bleating, somewhat 
suggestive of the cry of a goat. When heard it may be considered a 
sign of pleurisy with slight effusion, or of pleuro-pneumonia. 

Amphoric voice, or "the echo," as it is sometimes called, is a 
musical sound, of a somewhat hollow, metallic character, like that 
produced by blowing into an empty bottle. It is sometimes produced 
in large cavities within the lung, but is especially incident to pneumo- 
thorax. 

Increased bronchial whisper is a sound in which the whis- 
pered words are abnormally intense, and higher in pitch than the 
normal bronchial whisper. It has the same significance as exagger- 
ated vocal resonance. 



SUCCUSSION. 

The succussion or splashing sound is pathognomonic of one 
affection — namely, pneumo-hydrothorax. 

It is obtained by jerking the body of a patient with a quick, some- 
what forcible movement, the ear being very near or in contact with 
the chest. 

The sound is like that produced when a small keg, partially filled 
with liquid, is shaken. The only liability to error is in confounding 
this splashing sound with that sometimes produced within the 
stomach ; but attention to concomitant signs and the symptoms will 
always protect against this error. 



DISEASES OF THE NASAL PASSAGES. 



263 






ASSOCIATION OF THE PHYSICAL SIGNS (DA COSTA). 

" As many of the signs elicited by the various methods of physical 
diagnosis depend on the same physical conditions, they may be 
studied in groups. The following will be usually found to be asso- 
ciated : 

Auscultation 



Percussion. 


OF 


Auscultation 


Vocal 


Physical Conditions. 




Respiration. 


of Voice. 


Fremitus. 




Clear, .... 


Vesicular 


Normal vocal 


Unimpaired. 


Lung tissue healthy or 




murmur or 


resonance. 




nearly so ; at any rate, 




its modifi- 






no increased density 




cation. 






from deposits, etc. 




Bronchial, 


Bronchophony. 


Increased. 


Solidification of pulmon- 




or harsh 






ary structure. 


Dull, 


respiration. 










Absent respi- 


Absent voice. 


Diminished 


Effusion into pleural sac. 




- ration. 




or absent. 




Tympanitic, . 


Cavernous or 
feeble, ac- 


Uncertain ; 
cavernous or 


Uncertain ; 
mostly di- 


Increased quantity of air 
within the chest, due to 




cording to 


diminished. 


minished. 


a cavity or to overdis- 




cause. 






tention of the air cells. 


Amphoric or 
metallic. 


Amphoric or 
metallic. 


Amphoric or 
metallic. 


Mostly di- 
minished. 


Large cavity with elastic 
walls. 


Cracked 


Cavernous 


Cavernous 


Uncertain. 


Generally a cavity com- 


metal sound. 


respiration. 


respiration. 




municating with a bron- 
chial tube. 



DISEASES OF THE NASAL PASSAGES. 



ACUTE NASAL CATARRH. 

Synonyms. Acute rhinitis; acute coryza; "cold in the head." 
Definition. An acute catarrhal inflammation of the mucous 
membrane (pituitary or Schneiderian membrane) lining the nose and 
the cavities communicating with it ; characterized by feverishness, 
feeling of fullness and discomfort in the head, and attended with dis- 
charges of fluid, watery, mucous, or mucopurulent in character. 

Pathological Anatomy. Hyperemia of the mucous mem- 
brane, attended with redness, swelling, and deficient secretion. This 
tumefaction is partly increased by an (Edematous infiltration, causing 
a quantity of colorless, salty, and very thin liquid to flow from the 



264 PRACTICE OF MEDICINE. 

nose. The secretion soon assumes the character of thick, tenacious 
mucus or muco-pus, due to the desquamation of the epithelium of the 
nasal mucous membrane, and a copious generation of young cells, 
the hypersemia and the swelling of the membrane diminishing. 

The respiratory portions of the nasal fossae are more markedly 
affected than are the olfactory. 

Rarely, and then in new-born infants and those affected with the 
eruptive fevers, the exudation in the nasal passages is of a fibrinous 
nature, somewhat similar to that observed in diphtheria. 

Causes. Atmospherical changes are the most frequent and in- 
fluential. Exposure of the neck to a draught of cold air, or of the 
feet and ankles to cold and dampness, or changing from a warm to a 
cold atmosphere suddenly, are among the most usual causes. Irri- 
tating gases and vapors, dust, certain powders, as ipecac and tobacco. 
The scrofulous taint and the rheumatic diathesis seem to render the 
mucous membrane susceptible to frequent attacks. 

Acute coryza is usually present in the initial stage of measles and 
influenza ; nearly always present in facial erysipelas. 

•Epidemic influence occasionally prevails on an extensive scale. 
The poison of syphilis or the use of the iodide of potassium not in- 
frequently act as exciting causes. 

At times the catarrh seems to spread by contagion. 

Symptoms. "A cold in the head" is usually preceded by a 
feeling of lassitude or weariness and more or less frontal headache ; 
then occur irregular chilly sensations in the back, followed by more or 
less feverishness and an uncomfortable feeling of dryness in the nares, 
with a strong inclination to sneeze. This is soon followed by an 
abundant watery a7id saline discharge, which is continually dripping 
from the nostrils, or occasions an attack of sneezing followed by 
blowing the nose, which relieves the congested and swollen mem- 
brane for a few moments. The relief is temporary, however, the 
fullness of the head and difficult obstructed nasal respiration rapidly 
returning. The anterior nares are red and inflamed, and the eyes 
red and suffused with tears, through partial or entire closure of the 
tear ducts. The discharge soon assumes a purulent character. The 
voice has a peculiar tone, rather nasal and muffled in character. 
Within a few days the swelling subsides and secretion lessens, 
health being restored in about ten days from the beginning of the 
attack. 



DISEASES OF THE NASAL PASSAGES. 265 

When the attack has almost terminated, hard crusts may form 
within the nostrils, either on the septum or turbinated bones, which 
are with difficulty expelled by blowing the nose. 

Complications. Irritation and swelling of the upper lip, from 
repeated blowing of the nose and the constant contact of the irri- 
tating discharge. 

Extension of the catarrh to the ethmoid or sphenoid cavities cr 
frontal sinus, causing increased and severe frontal headache; or to 
the antrum of Highmore, causing tenderness over one or both 
cheeks. 

Extension to the Eustachian tube and middle ear, causing impaired 
hearing ; or the pharynx or larynx, causing cough. 

Duration. In mild cases about one week ; severe cases continue, 
more or less marked, for two weeks. 

Prognosis. Favorable if early and proper treatment be insti- 
tuted; if neglected, the catarrh tends to become chronic. In very 
young infants, if the catarrh is not rapidly relieved, loss of flesh and 
strength occur, from inability to nurse. 

Treatment. Attacks the result of atmospherical causes may be 
aborted by the early administration of quinines sulphas, gr. x-xv (0.6-1 
Gm.), with morphince sulphas, gr. % (0.016 Gm.), or the early use of 
pulvis ipecacuanha et opii, gr. v (0.3 Gm.), repeated in two hours. 
Buckley says an acute cold can be aborted by using sodii bicar- 
bonalis, gr. xx (1.3 Gm.) in f^ij (60 Cc.) of a hot fluid every half hour 
for three doses and the fourth dose in one hour. 

The following errhine used at the very onset has proved successful 
in aborting many attacks : 

R . Alumenis, 

Bismuthi subcarb. , 

Pulv. camphora?, aa gr. xx aa 1.3 Gm. 

Morphinoe hydrochlor. , gr. ij .13 Gm. M. 

Ft. chart. No. xx. 

Sig. — Insufflate one powder in each nostril after clearing the nose. 

If the attack has already developed, relief is soon afforded by 
tinctura belladonna', mjj (o 12 Cc), every hour until six doses are 
taken, after which one drop every two or three hours until the physi- 
ological actions of the drug are produced ; if much fever be present, 
tinctura aconiti, Tr\j-ij (0.06-0.12 Cc), may be added; the addition 
of camphora is of value : in fact, camphora in full doses at the onset 
2 3 



266 PRACTICE OF MEDICINE. 

and locally will often abort an acute catarrh. The following combi- 
nation of Dr. Sajous is often successful : 

R. Ammonii chlor. , ^ij 2.6 Gm. 

Tinct.opii, Tr^xxx 2. Cc. 

Sacch. alb., 5jj 4. Gm. 

Aq. camphorae, f^j 30. Cc. M. 

Sig. — One teaspoonful in water every hour or two. 

Attacks of acute rhinitis unaccompanied by febrile reaction are 
generally promptly aborted by a four per cent, solution of cocaines 
hydrochloras, dropped in the nostrils, repeated every half hour : 

With either of the above plans may be added one of the following 
err nines : 

R. Bismuth, subnit., ^vj 24. Gm. 

Pulv. acaciae, spj 8. Gm. 

Morphinae hydrochlor. , gr. ij .13 Gm. 

Sig. — Every hour or two. (Ferrier.) 

Or— 

R. Pulv. cubebae, srj 4. Gm. 

Bismuth, subnit., g ij 8. Gm. 

Morphinae hydrochlor., .... gr. ij .13 Gm. M. 
SlG. — Used by insufflation every two or three hours. 

Acute coryza occurring in infants at the breast is controlled by 
either one of the following errhines, thrown into the nose with a 
powder blower : finely powdered saccharum fiurificatum (white), or 
equal parts of finely powdered saccharum purificaium and camfthora, 
or Robinson's errhine of saccharum fturificaium and ca?nfthora y each 
half ounce (15 Gm.) finely powdered, and acidum tannicum, gr. xl 
(2.6 Gm.). 

Attacks of nasal catarrh due to the poison of syphilis should at 
once be placed upon the proper constitutional treatment. 

Attacks of nasal catarrh associated with the eruptive or mild fevers 
require no special treatment. 

It is well to remember that attacks of nasal catarrh occurring in 
very young children are generally the result of hereditary syphilis, 
and should be treated accordingly. 



DISEASES OF THE NASAL PASSAGES. 267 



CHRONIC NASAL CATARRH. 

Synonyms. Chronic rhinitis ; chronic coryza. 

Definition. A chronic inflammation of the mucous membrane 
lining the nasal passages, with more or less alteration of structure ; 
characterized by a sensation of fullness in the nares, increased secre- 
tion, and a perversion of the special sense of smell and of hearing. 

Causes. The result of repeated attacks of the acute variety ; 
inhalation of irritating vapors and dust ; syphilis and scrofula. 

Pathological Anatomy. The mucous membrane of the nares 
is thickened, of a dark-red, sometimes grayish color, the superficial 
veins dilated and varicose, often forming polypoid enlargements. In 
many cases there is ulceration of the structure, with more or less loss 
of substance ; the secretion is thick, tough, of a greenish character, 
and often very foetid ; large collections of dried mucus are often 
formed upon the turbinated bones and septum. 

Symptoms. A feeling of fullness in the nares, increase of the 
secretion, the character being thick and greenish, which, dropping 
posteriorly into the pharynx, causes paroxysms of " hawking," 
which are more marked in the morning immediately after rising. 

The special sense of 'smell 'is more or less impaired, and in many in- 
stances entirely abolished ; the special sense of hearing is more or less 
diminished, from an extension of the inflammation to the Eustachian 
tubes ; the voice has a peculiar nasal intonation. 

An almost constant dull frontal headache, associated with a feeling 
of weight, showing the extension of the disease to the infundibulum 
and frontal sinus. 

Sudden changes of temperature cause acute exacerbation of these 
symptoms, when there is superadded difficult nasal respiration. 

If ulceration of the nares occur, the discharge has a foetid odor. 
This condition is termed ozcena. 

From extension of the inflammation to the nasal duct or its ob- 
struction, the tears flow over the malar eminence {epiphora), leading 
to more or less congestion of the eyes. 

Diagnosis. Hypertrophy of the turbinated bones and naso- 
pharyngeal catarrh are constantly misnamed chronic nasal catarrh. 
The rhinoscope readily determines the diagnosis. 

Prognosis. Permanent cure is seldom obtained ; the disease 



268 PRACTICE OF MEDICINE. 

being so decidedly chronic and obstinate, the treatment is of neces- 
sity protracted, and the majority of patients tire of it before a com- 
plete cure is effected. 

Treatment. If it depends upon diathetic conditions, the cause 
must be ascertained and treatment directed accordingly. 

When no diathetic cause can be determined, attention should be 
paid to the general health, the secretions constantly attended to, and 
the diet be nutritious and digestible. 

Cleanliness of the nasal passages is of the utmost importance, and 
is best effected by the post-nasal syringe, with either simple or medi- 
cated tepid waters, or a cleansing solution, such as DobeH's — to wit : 

]J. Acidi carbolici, gr. j .065 Gm. 

Sodii bicarbonat., 

Sodii borat., aa gr. v aa .3 Gm. 

Glycerini, f t ^j 4. Cc. 

Aqua, f jfj 30. Cc. 

Sic — As a spray or with a proper syringe. 

Or the following combination of Dr. Sajous: 

Be . Sodii bicarb. , 

Sodii bibor., aa gr. viij aa .52 Gm. 

Ext. pinus canad. fid., TT^ xv I. Cc. 

Glycerini, f t Zij 8. Cc. 

Aqua, adfgiv ad 120. Cc. M. 

SlG. — Apply with atomizer three or four times daily. 

After which decided benefit follows the use of one of the following: 

R. Acidi borici, gr. xxx 2. Gm. 

Bismuth, subnit. , gij • 8. Gm. 

Morphinse hydrochlor., .... gr. j .065 Gm. M. 

Or— 

Be. Pulv. sanguinaria gj 4- Gm. 

Acid, tannici, gr. v .3 Gm. 

Pulv. camphorrc. gj 4. Gm. 

Bismuth, subnit., 3 i j 8. Gm. M. 

SlG. — To be used by insufflation or as a snuff every three or four hours. 

Or— 

$ . Ammonii chloridi, ^j 4. Gm. 

Glycerini, . . fgij 8. Cc. 

Ext. pinus canad. fid., f 5 j 30. Cc. 

Aquae destil., adf^ij ad 60. Cc. 

SlG. — Five or ten drops, dropped into each nostril two or three times a day, 
or applied with a camel's-hair brush. 



DISEASES OF THE PHARYNX. 269 

Or the following pleasant mixture may be applied to each nostril : 

R. Tinct. benzoin., f ^ iv 15. Cc. 

Tinct. guaiaci, fgj 4. Cc. 

Chloroformi, TT\,x .6 Cc. 

Tinct. myrrh., . . , . . . . fgss 2. Cc. 

01. amygd., r^v .3 Cc. M. 

Sig. — A few drops in each nostril once, or oftener, a day. 



DISEASES OF THE PHARYNX. 



ACUTE CATARRHAL PHARYNGITIS. 

Synonyms. Catarrhal tonsillitis ; angina catarrhalis ; acute 
"sore throat." 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the tonsils, uvula, soft palate, and pharynx ; character- 
ized by rigors, fever, painful deglutition, coughing, or constant desire 
to clear the throat, with a more or less decided nasal intonation of 
the voice. 

Causes. Exposure to cold and damp ; swallowing hot fluids or 
food; during the prevalence of scarlatina, measles, erysipelas, influ- 
enza, diphtheria, or variola. It is attributed to some form of bacteria 
by numerous observers. 

Pathological Anatomy. The mucous membrane and sub- 
mucous tissues of the uvula, soft palate, fauces, tonsils, and pharynx 
are congested, red, and swollen ; the secretion is at first lessened or 
entirely arrested, later it is increased, but of a thick, tenacious, opaque 
character. The swelling is most evident at the uvula, due to the 
amount of relaxed submucous tissue, which is especially thick and 
long, often resting on the root of the tongue ("the palate is down "). 
Frequently one or both tonsils are swollen to such an extent that 
the fauces are completely occluded, and the condition is mistaken for 
the graver phlegmonous, tonsillitis. 

In severe attacks of catarrhal angina, white or grayish-white mem- 
branous masses form in small, irregular, roundish spots on the red- 



270 PRACTICE OF MEDICINE. 

dened mucous membrane of the tonsils, soft palate, and pharynx, 
causing the affection to be frequently mistaken for diphtheria. 

Symptoms. The onset is usually sudden, with rigors, fever, 
thirst, headache, loss of appetite, coated tongue, bad taste, foul 
breath, dryness in the throat, painful deglutition, and constant desire 
to clear the throat, due to the increased length of the uvula ; as the 
inflammation proceeds the secretions are increased, the fluid often 
filling the mouth, causing a constant desire to swallow, each act being 
associated with acute pain. Not infrequently earache adds to the 
patient's distress, from extension of the "catarrh " to the Eustachian 
tubes and tympanum. 

In severe attacks of catarrhal pharyngitis, cases which, from the 
intense hyperaemia, have been termed erysipelatous or erythematous 
pharyngitis, the muscles of the palate are infiltrated with serum, 
which greatly interferes with their function. Under normal conditions 
the contraction of the muscles of the anterior half arches of the palate 
prevents the return of food and drink into the mouth ; while the con- 
traction of the muscles of the posterior half arches, together with the 
uvula, closes the passage to the nose; if the function of these muscles 
be impaired, fluids would be driven through the nose or back into the 
mouth by the contractions of the pharynx in the act of deglutition. 

In all affections of the pharynx a nasal tone is pathognomonic, 
especially if the muscles of the half arches are interfered with. 

Varieties. Exanihematous pharyngitis is the form of the affec- 
tion complicating the acute infectious diseases, such as scarlatina, 
measles, influenza, and small-pox. 

Erysipelatous pharyngitis \s the form complicating facial erysipelas ; 
rarely, however, the affection begins in the pharynx, spreading to the 
face and other parts. The association of nasal inflammation with 
erysipelas should not be forgotten. 

Gangrenous pharyngitis may occur with diphtheria, scarlatina, 
erysipelas, small-pox, and typhoid fever. The symptoms assume a 
typhoid (depressed) character, the termination being usually fatal. 

Phlegmonous pharyngitis is the variety associated with an accu- 
mulation of pus in the submucous and deeper tissues of the pharynx, 
constituting a retro pharyngeal abscess. This variety of pharyn- 
gitis may follow the penetration of a sharp piece of bone or be sec- 
ondary to caries of the cervical vertebrae. 

Fibrinous pharyngitis, or, as it is sometimes termed, pseudo-mem- 



DISEASES OF THE PHARYNX. 271 

branous, is considered with croup and diphtheria, of which it is a 
variety. 

Diagnosis. On account of the great swelling of the tonsils, it 
may be mistaken for acute tonsillitis ; but the mild inflammatory 
symptoms should prevent the error. 

Cases with membranous deposits upon the tonsils, soft palate, and 
pharynx, are no doubt often misnamed diphtheria : the marked differ- 
ence in the constitutional symptoms and the absence of the Klebs- 
Loeffler bacillus should prevent the error. 

Prognosis. Favorable, the affection terminating in three or four 
days by the discharge of a quantity of thick, opaque mucus. 

Treatment. If the attack is the result of exposure to cold or 
damp, or a symptom of some one of the infectious diseases, the very 
best results follow the application of sodii bicarbonas by insufflation. 
Opium in some form, alone or combined with ipecac or camphora, 
will often abort an attack of catarrh. Salol, gr. iij (0.2 Gm.), and phen- 
acetin, gr. iij (0.2 Gm.) combined \\\\hpulv. camphorcz, gr. j (0.065 Gm.) 
(reducing size of dose for children,), repeated four to six times daily, 
are most valuable remedies for relieving the pain in all varieties of 
acute anginas. Sodii salicylas, gr. x-xv (0.6-1 Gm.) hourly until 
five or six doses are taken, often acts like a specific. If the fever be 
marked, advantage follows the addition of small doses of ii?ictura 
aconiti. In children no one drug can compare with small repeated 
doses of tinctura aconiti. Excellent results often follow the use of 
nuclein (Aulde), gr. j — iij (0.065-0.2 Gm.), or tt\j-v (0.065-0.3 Cc.) 
every hour or two. 

Locally, cocaine painted over the inflamed parts, of the strength of 
a four per centum solution, or used in the form of lozenges, is a val- 
uable remedy. Holding small pellets of ice in the mouth is useful, 
or the application of either heat or cold to the angles of the jaws. 
Gargles or sprays of aluminis [gr. viij (0.52 Gm.) ; aquae, f^j (30 Cc.)] ; 
ammonii chloridum [gr. xx (1.3 Gm.) ; aquae f^j (4 Cc.)] ; or potassii 
chloras [gr. x (0.6 Gm.) ; aquae f£j (30 Cc.)], used at frequent inter- 
vals, often allay the congestion and consequent swelling. For the 
gangrenous variety stimulants and the local use of argenti nitras. 

If a retro-pharyngeal abscess develop, evacuate the pus early and 
give quinines sulphas and ferrum for the constitutional symptoms 
which may develop. 



272 PRACTICE OF MEDICINE. 



ACUTE TONSILLITIS. 

Synonyms. Amygdalitis; quinsy; phlegmonous pharyngitis. 

Definition. An acute parenchymatous inflammation of one or 
both tonsils, with a strong tendency toward suppuration ; character- 
ized by moderate fever, pain in the throat, a constant desire to relieve 
the throat, painful and difficult deglutition, impeded respiration, and 
more or less muffling of the voice. 

Causes. Generally attributed to exposure to cold, but, in the 
majority of instances, the exposure is so slight that there must be a 
predisposition to the affection, for persons once affected are particularly 
prone to repeated attacks upon the slightest exposure. 

Pathological Anatomy. One or both tonsils will be seen, on 
inspection, to project from its bed, as a rounded, deep red body, 
which may even extend beyond the median line, when they may en- 
tirely occlude the isthmus of the fauces; the half arches and posterior 
border of the soft palate are reddened and somewhat swollen. The 
surface of the tonsils is often covered with small, yellowish points, 
which closely resemble patches of false membrane, but careful in- 
spection will show that they are beneath the mucous membrane, 
being only the distended follicles of the gland. The mucous mem- 
brane of the fauces and pharynx is more or less red and swollen. 

Symptoms. Onset more or less sudden, with rigors, rise in tem- 
perature, io2° to 104 F '. ; full, frequent pulse, 100 to 120; headache, 
thirst, pain and swelling at the angle of the jaw with a constant 
desire to clear the throat ; difficult and painful deglutition, from the 
enlarged tonsils almost closing the fauces, when the respiration is 
more or less impeded ; the voice is more or less muffled, and attempts 
at phonation increase the pain. 

Darting pains along the Eustachian tubes are of frequent occur- 
rence, the patient complaining of earache and more or less deafness. 

If suppuration be imminent, the throat becomes more painful, the 
character of the pain throbbing, the febrile phenomena increase, with 
more or less depression, the symptoms seeming to be of great danger, 
when suddenly, after an effort at vomiting, or spontaneously, the ton- 
sillar abscess bursts, a quantity of pus escapes from the mouth, and 
prompt relief follows. 

Duration. The disease lasts from three to seven days, terminat- 



DISEASES OF THE PHARYNX. 273 

ing either by suppuration or the gradual resolution of the enlarged 
glands. 

Diagnosis. Tonsillitis can hardly be mistaken for any other 
affection if the fauces are inspected. 

Prognosis. In the majority of cases the result is favorable, it 
very rarely proving fatal, except in children, and only then by ob- 
structing the respiration, and, at the same time, so seriously interfer- 
ing with nutrition that the child's strength fails. 

Treatment. The first indication in an attack of acute tonsillitis 
is a prompt and efficient purgative, and none is better than calomel : 

R . Hydrarg. chlor. mitis, gr. v .3 Gm. 

Sodii bicarbonatis, gr. v .3 Gm. M. 

Ft. chart. 

Followed in six or eight hours by a saline. I can confidently recom- 
mend sodii salicylas, gr. x-xv (0.6-1 Gm.), every hour or two until a 
drachm and a half to two drachms are administered. It should be 
well diluted. Cinchonidincz salicylas, gr. v (0.3 Gm.), every couple 
hours is often beneficial. 

Should the febrile action be high, tinctura aconiti in small doses 
frequently repeated, either alone or alternating with sodii salicylas, 
rapidly reduces the temperature and the frequency of the pulse, and, 
by its local action, lessens the pain and swelling. If from any cause 
the internal use of aconitum be contra-indicated, the tinctura aconiti 
may be diluted with glycerinum and painted over the affected parts. 

Cases not seen until two or three days after the onset are benefited 
by the following : 

R. Tincturoe ferri chloridi, fsjij 8. Cc. 

Glycerini, adf^ij ad 60. Cc. M. 

SiG. — Teaspoonful every two hours, undiluted. 

This palatable mixture, suggested by Dr. Bosworth, acts as a local 
astringent in passing over the inflamed tonsils, and should not be 
followed with water or food for an hour at least. 

During the past five years I have had excellent results from nuclein 
(Aulde), gr. j-iij (0.065-0.2 Gm.), or Ti\j-v (0x65-0.3 Cc), every hour, 
the patient sucking pellets of ice, and having hot dry applications to 
the angles of the jaw. 

Scarification, a long, sharp bistoury being used to make five or six 
24 



274 PRACTICE OF MEDICINE. 

cuts, affords great relief when the tonsils are much inflamed ; the ex- 
ternal 'use of ice over the site of the glands, and small pellets allowed 
to dissolve in the mouth, afford great relief. If the application of 
cold be objectionable, heat may be substituted in the form of warm 
compresses or poultices. 

In all cases recourse to such general therapeutic measures as are 
calculated to guide the morbid action to a favorable issue ; the bowels 
should be kept open and the skin and kidneys active ; the diet 
should be in the shape of gruels, as it is impossible for the patient 
to swallow any solid substance, and in cases where even gruels 
cause painful deglutition, thin oatmeal gruel can be used with 
advantage. 

When suppuration cannot be averted, hot applications should be 
applied to the angles of the jaws, hot gargles and the steam atomizer 
resorted to, medicated with opium, belladonna, benzoin, or cocainae 
tiydrochloras, and as soon as fluctuation can be detected the abscess 
should be opened. Also during this stage administer quinines sulphas, 
gr. iij-v (0.2-0.3 Gm.) every three or four hours. After the acute 
symptoms have subsided, assist the return of the glands to their nor- 
mal condition by the topical application of cupri sulphas [gr. xx (1.3 
Gm.) aquas f^j (30 Cc.)], or liquor ferri subsulphatis [f3j (4 Cc.) 
aquae {$] (30 Cc.)]. 



DISEASES OF THE LARYNX. 



ACUTE CATARRHAL LARYNGITIS. 

Synonyms. Catarrhal laryngitis ; " sore throat." 

Definition. An acute catarrhal inflammation of the mucous 

membrane of the larynx ; characterized by feverishness, diminished 

or suppressed voice, painful deglutition, and more or less difficulty 

of respiration. 

Causes. Atmospherical changes ; cold draughts of air, either 

directly inspired or an exposure of parts or all of the body. Cold, 



DISEASES OF THE LARYNX. " 275 

wet feet. Inhalation of irritating vapors, such as gases, smoke, or 
ammonia, or the inhalation of dust. Prolonged efforts at public speak- 
ing or singing or the same efforts under difficulties. In children, from 
violent fits of crying. 

Pathological Anatomy. In mild cases there is a transient 
congestion (hyperaemia) of the mucous membrane over the entire, but 
more commonly circumscribed portions of, the larynx, with more or 
less swelling and diminished secretion ; the mucous membrane soon 
returns to its normal condition, the secretion being slightly increased. 

Symptoms. The attack begins rather suddenly with a feeling of 
dryness, rawness, and tickling, referred to the larynx with the sensa- 
tion of the presence of a foreign body in the throat, and with hoarse- 
ness and a disposition to cough. Deglutition causes pain by the 
upward movement of the larynx and by the pressure of the food on 
the larynx as it passes along the gullet. Attempts at speaking are 
attended with more or less distress and the larynx is tender on 
pressure. 

Coughing, from the onset, of a noisy, harsh, hoarse, or toneless 
character and the act of coughing attended with a sensation of 
scratching in the larynx. The first day or two there is scanty expec- 
toration, but in a short time the secretion is increased, giving the 
cough a loose character. In the early stages the sputa may be 
slightly streaked with blood. Rarely a hemorrhage occurs from the 
mucous membrane of the larynx. The voice is at first decidedly 
hoarse, soon followed by complete aphonia. The respiration is but 
slightly, if at all, affected in adults. There may be more or less 
febrile reaction. In children the onset is with fever, white coated 
tongue, frequent, tense pulse, hot skin and flushed face, embarrassed 
respiration, the voice hoarse and whispering, with harsh, ringing, 
croupy cough and great restlessness. During the night the child is 
subject to suffocative attacks (laryngismus stridulus). 

Lary7igoscopic appearances. These vary with the severity of the 
attack and the stage of the inspection. In mild cases, at an early 
period, the mucous membrane presents a bright red appearance. 
Severe cases present, in addition to the bright redness, swelling of the 
mucous membrane to such an extent at times as to conceal the vocal 
cords, they appearing only as slender threads of a reddish tint. At 
times the mucous membrane presents the appearance of erosions or 
ulcerations, due to the desquamation of the epithelium. 



276 ' PRACTICE OF MEDICINE. 

Duration. Usually about one week ; if very severe, two or three 
weeks may elapse before the larynx returns to its former con- 
dition. 

Prognosis. Simple catarrhal laryngitis never terminates fatally. 

Treatment. Confinement to an apartment of uniform tempera- 
ture, the air kept moist by the vapor of water, particularly for chil- 
dren. 

Locally, a hot pack should be kept constantly wrapped about the 
throat, and if its application is preceded by the temporary use of a 
weak mustard plaster, the relief afforded is more rapidly obtained. 
At the very beginning of an attack the feet should be placed in a hot 
mustard foot bath, and either a saline cathartic or mercurial purgative 
administered. 

Prompt action on the skin at the very onset will frequently shorten 
the duration of a catarrh of the larynx. Use for this purpose in adults 
pulvis ipecacuanha et opii, gr. iij (0.2 Gm.), combined with poiassii 
nitras, gr. iij (0.2 Gm.), every three or four hours. If there be much 
febrile reaction, benefit follows the use of tinctura aconiti, Tr\J — ij 
(o 06-0.12 Cc), every half hour until five or six doses are taken, after 
which every hour or two, combined with tinctura opii, n\j-v (0.06-0.3 
Cc.) ; or diaphoresis may be produced by antimotiii et potassii tartras, 
gr. sV- 3V (0.003-0.002 Gm.), every hour, or by the hypodermic injec- 
tion of pilocarpines hydrochloras, gr. ]4, (0.022 Gm.). 

For children, several doses of the following powder a couple of 
hours apart, until the bowels are freely moved : 

R . Hydrargyri chloridi mitis, .... gr. ^ .008 Gm. 

Pulvis ipecacuanhas, gr. j4 - 00 ^ Gm. 

Sacch. lactis, gr. ij .13 Gm. 

To be followed by — 

R. Potassii citrat., £)iv 5.3 Gm. 

Tinct. aconiti, n\v .3 Cc. 

Tinct. opii camphorat., f 3 ij— iv 8. -15. Cc. 

Syr. scillae, fzij 8. Cc. 

Syr. tolu, ad f 5 iij ad 90. Cc. M. 

SlG. — One teaspoonful every two hours. 

If a tendency to spasm of the glottis obtains, full doses of the bro- 
mides should be administered at once. 



DISEASES OF THE LARYNX. 277 

Inhalations from the onset are not only soothing, but curative, in 
their actions. Either of the following are recommended : 

R. Infusihumuli, Oj 475. Cc. 

Vinegar, f^ss-j lS-~3°- Cc. 

SlG. — Inhale hot every hour. 

R. Tinct. benzoin, comp., ...... f^j-ij 4.-8. Cc. 

Aquas bullae, Oj 475. Cc. 

SlG. — Inhale hourly. 

The local application of cocaine is of great benefit. 

Attacks of acute laryngitis occurring from efforts in public speaking 
or singing are wonderfully benefited by the use of acidum nitricum 
dilutum, TT^ij-v (0.12-0.3 Cc), every hour or two ; or atropines sulph., 
gr. ^j (0.00022 Gm.), repeated in an hour for several doses. 

The patient should abstain altogether from the use of the voice and 
from taking food or drink of an irritating character. 



(EDEMATOUS LARYNGITIS. 

Synonym. (Edema 'of the glottis. 

Definition. An acute inflammation of the mucous membrane of 
the larynx and that about the glottis, with an infiltration of the areolar 
tissues by a serous, sero-purulent, or purulent fluid ; characterized by 
obstructed or stridulous breathing and dysphonia or aphonia. 

Causes. The result of acute laryngitis ; abscess in or about the 
throat or tonsils; erysipelas of the face ; scarlatina; small-pox; 
Bright's disease; syphilis of the larynx. Rare in children. 

Pathological Anatomy. Infiltration into the loose connective 
tissue of the ary-epiglottic folds, the glosso-epiglottic ligament, the 
base of the epiglottis, and the inter-arytenoid space. If the true 
vocal cords are inflamed, their color changes, and instead of appear- 
ing white, glistening, and brilliant, they are dull, grayish-red, or 
violet-red in patches. If the swelling be the result of purulent infil- 
tration, the parts present a deeply congested color, with here and 
there spots of a yellowish hue. 

Serous infiltration, sufficient to cause fatal oedema, disappears 
with death, leaving but slight traces to account for the formidable 
symptoms. 



278 PRACTICE OF MEDICINE. 

Symptoms. The onset is much the same as a simple catarrhal 
laryngitis with a gradually increasing impediment to the respiration. 

The patient experiences the sensation of a foreign body in the throat, 
and after a short time a difficulty of breathing, which ultimately 
threatens suffocation. The deglutition is rendered difficult owing to 
the swelling of the epiglottis ; the voice, at first muffled, gradually 
becomes weaker and weaker, until finally it is almost extinct; the 
cough at first is dry and harsh, but as the infiltration increases it 
becomes stridulous and suppressed ; there is no expectoration, except 
that after great effort to clear the throat a little frothy mucus is raised. 
The difficulty of respiration, as the disease progresses, becomes greater 
and greater, and the paroxysms of impending suffocatio?i more fre- 
quent. The inspiration is accompanied by a whistling sound char- 
acteristic of the narrow condition of the glottis ; the patient sits up in 
bed, his mouth open, gasping for breath, his eyes protruding, the 
whole body trembling with intense convulsive movements, and after 
a time a general cyanosis commences, the face assuming a bluish hue, 
all these symptoms continuing for a few moments, when slight relief 
occurs, to be again followed by another paroxysm, in one of which, 
if nature or art does not afford prompt relief, death occurs from 
asphyxia. 

A physical examination of the parts may be made by gently pass- 
ing the finger into the throat, when the epiglottis may be felt very 
much thickened, and the ary-epiglottic folds may have attained such 
tumefaction as to convey to the finger an impression similar to that 
which is given by touching the tonsils. 

Laryngoscopic appearance. The mucous membrane has a bright 
red appearance. The epiglottis has the appearance of a semi-trans- 
parent roll-like body, or it is often merely erect and tense. It is this 
condition of the epiglottis which explains the pain and difficulty in 
deglutition. Rarely the vocal cords are infiltrated. 

Diagnosis. Any disease which gives rise to dyspnoea may 
simulate ©edematous laryngitis, but the history of the case, together 
with a laryngoscopic examination, will generally furnish conclusive 
evidence of the nature of the malady. 

Prognosis. As a rule, unfavorable. If early and vigorous treat- 
ment be instituted, recovery is possible, but without it death is the 
inevitable result, the patient dying asphyxiated. Even when local 
measures have removed the obstruction to free respiration, the patient 



DISEASES OF THE LARYNX. 279 

is very likely to perish subsequently from exhaustion or blood poison- 
ing, or from pneumonia or other lung complication. The duration of 
infiltration of the larynx varies from a few hours to several days. 

Treatment. Prompt local treatment must be adopted in order to 
remove the laryngeal obstruction. Leeches placed over the sides of 
the larynx in mild cases may effect reduction in the oedema, rendering 
the subsequent progress free from danger. 

If the infiltration has already occurred and is slight in amount, 
scarification, guiding the instrument by the index finger of the oppo- 
site hand, may afford relief, or the hypodermic injection of pilocarpines 
hydroc Moras, gr. y^ (0.022 Gm.), repeated, may lessen the swelling. 

Niemeyer recommends the persistent use of small pellets of ice 
early in the attack, swallowed or held far back in the mouth until dis- 
solved. Trousseau recommends the inhalation or spray of a strong 
solution of asidiim tannicum. Prof. Da Costa suggests the applica- 
tion, as near the seat of the disease as possible, of liquor ferri sub- 
sulphatis (Monsel's solution), full or half strength. Mackenzie says 
the patient should be kept constantly under the influence of potassii 
bromidum. 

If these means fail, tracheotomy is indicated ; in those cases of 
sudden and rapid infiltration of the glottis or larynx occurring in 
Bright's disease, erysipelas, scarlatina, or syphilis of the larynx, and 
especially the former and the latter, tracheotomy should be performed 
at once. Intubation relieves the obstructed breathing while other 
means are combating the disease. 

In all cases of infiltration of the larynx stimulants should be boldly 
administered per rectum, if stomachic administration be impossible. 

If the infiltration be composed of pus, quinina: sulphas, gr. v (0.3 
Gm.) every four hours, and stimulants are indicated. 



SPASMODIC LARYNGITIS. 

Synonyms. Spasmodic croup ; false croup ; catarrhal croup ; 
child crowing. 

Definition. A catarrhal inflammation of the mucous membrane 
of the larynx, associated with temporary spasmodic contraction of the 
glottis; characterized by paroxysmal coughing, difficulty of breathing, 
and attacks of threatening suffocation. 



280 PRACTICE OF MEDICINE. 

Causes. Atmospherical changes or "taking cold"; excesses in 
eating and drinking ; excitement ; violent emotion, are all given as 
causes for simple croup. 

Pathological Anatomy. Congestion of the mucous membrane 
of the larynx, with slight swelling and deficient secretion, are the 
only changes that have thus far been noted. 

Symptoms. The attack occurs chiefly during the night, the 
child on retiring having either its usual health, or perhaps being 
a little feverish. After several hours of sleep the child is suddenly 
awakened by a paroxysm of suffocation, and a dry, harsh, ringing 
cough. After half an hour or an hour or two the breathing becomes 
easier, the cough less "croupy," the skin is covered with more or less 
perspiration, and the child falls asleep. The next day there is present 
cough of a loose character, the respiration being about normal. If 
no treatment be instituted, the same phenomena occur on the second 
night, the child being apparently well during the second day, the 
cough being less in amount ; phenomena of a similar character, but 
of much less severity, are present the third night, after which the dis- 
ease usually disappears. 

If the symptoms of the first paroxysm continue pronounced for two 
or three days, there is a strong probability that the inflammation may 
become fibrinous in character, or that true croup may develop. 

Diagnosis. The symptoms are so characteristic that it seems 
impossible for the affection to be mistaken for any other disease. 

Prognosis. Spasmodic or simple croup always terminates favor- 
ably. 

Treatment. During the paroxysm, the child should at once be 
placed in a hot bath and hot or cold cot?tpresses wrapped about the 
throat. These means should be preceded or followed by a mild 
emetic. The late Chas. D. Meigs always used aluminis, with or with- 
out syrupus ipecacuanha* ; Prof. Bartholow recommends hydrargyri 
subsulphas flavus (turpeth mineral) gr. j-iij (0.065-0.2 Gm.); Prof. 
Da Costa suggests the cautious use of apomorphina? hydrochloras, 
gr. y 1 ^ (0.006 Gm.), hypodermically. A favorite remedy for emesis, 
in Germany, when the jaws are not closed, and one that is highly 
successful, is tickling the fauces with the finger or a feather until 
vomiting is produced. Inhalations of chloroformu7n often at once 
relieve the spasms, but must never be employed by non-professional 
persons. Having by any of the above means broken up the spasm 



DISEASES OF THE LARYNX. 281 

of the larynx, a prompt cathartic should be administered (R. Hydrar- 
gyri chloridi mitis, gr. ij (0.13 Gm.), sodii bicarbonatis, gr. iij (0.2 Gm)., 
M. et ft. chart, no. j), followed in six to eight hours, if not sufficient 
results, with oleum ricini, after which : 

R. Tincturse aconiti, TT\^viij .5 Cc. 

Syr. ipecacuanhoe, fgiss 6. Cc. 

Tincturae opii camphorat., . . . f^iij 12. Cc. 

Liquor potassii citratis, . . . ad f 3 iij ad 90. Cc. M. 
SiG. — One teaspoonful every hour or two. 



CROUPOUS LARYNGITIS. 

Synonyms. Membranous croup ; true croup. 

Definition. An acute inflammation of the mucous membrane of 
the larynx, attended with the exudation of a tough secretion — the 
false membrane — and the occurrence of spasm of the glottis ; charac- 
terized by febrile reaction, frequent ringing cough, dyspnoea, with 
loud respiratory sound, and altered or extinct voice, showing a strong 
tendency toward death by asphyxia. 

Causes. A disease of childhood, most common in strong, vigor- 
ous, well-nourished males. Certain families present a strong heredi- 
tary tendency. Most common during a humid winter. 

We cannot assent to the dictum of some authorities, that laryngeal 
diphtheria and croupous laryngitis are identical. 

Pathological Anatomy. Intense hypertzniia of the mucous 
membrane of the larynx, associated with swelling, aedeina, and marked 
redness. There soon appears on the surface of the mucous mem- 
brane a grayish pellicle, rapidly coalescing and becoming thicker, — 
the opaque, false membrane, — which differs in extent, thickness, and 
adhesiveness in different portions of the larynx. In all cases the 
false membrane is found on the vocal cords and inner surface of the 
epiglottis. The first exudation (membrane) softens by the serum 
which is exuded, and is then mechanically dislodged by acts of 
coughing or vomiting, but is followed by successive deposits upon the 
mucous membrane. 

When the false membrane is detached, the mucous membrane of 
the larynx is found unaffected, so far as the loss of structure is con- 
cerned. Several successive crops of membrane may form after the 



282 PRACTICE OF MEDICINE. 

detachment, or it may entirely cease to form after the removal of the 
first exudation. • 

On microscopical examination the false membrane is found to be 
composed of a fine network of fibrillas, holding in their interstices 
leucocytes of an albuminous or fibrinous nature. 

The false membrane may extend into the pharynx, but especially 
is it liable to extend into the trachea and bronchial tubes, and, as the 
inflammation extends downward, the character of the exudation 
changes from fibrinous to muco- purulent. 

Symptoms. The onset of "true croup" is either suddenly, by 
an attack of spasmodic croup, or gradually, as an acute catarrh of 
the larynx, rapidly increasing in severity, with a feeling of heal in the 
throat, huskiness of the voice, harsh cough, fever, and thirst, the 
hoarseness soon becoming marked, and the cough having a metallic, 
" croupy" character, rapidly changing to a. stridulous, husky sound; 
every few minutes the child takes a sudden, deep, stridulous inspira- 
tion, the voice becoming more and more husky. Difficulty of breath- 
ing now follows ; the child is unable to lie down, or if exhausted by 
the efforts at inspiration, it is quiet for a moment, it soon starts up in 
fright, breathing more heavily, with a shrill, whistling inspiration. 
Soon, from the narrowing of the glottis, from the presence of the 
membrane, the expiration becomes difficult and noisy, and suffocation 
seems imminent from the paroxysmal attacks of spasm of the glottis ; 
the child tosses wildly about, tears at its throat, as if to remove some 
obstacle, the face becoming cyanosed, the alae of the nose working 
rapidly, the mouth wide open, the inspiratory efforts gasping, the 
body covered with a profuse sweat, and death seems imminent, when, 
suddenly, the spasm is relaxed, air enters the chest, the breathing be- 
comes somewhat easier, and the child, exhausted and partially stupe- 
fied, drops into a fitful sleep of a few moments' duration. 

The suffocative attacks return at short intervals, or there occur 
decided remissions between them, considerable portions of the false 
membrane being expelled, allowing the child to fall into a refreshing 
sleep. 

In those cases which tend to a favorable termination, the appear- 
ance of improvement noted between the suffocative attacks is main- 
tained, the paroxysms of suffocation becoming less frequent, the 
expectoration of membrane more marked, the difficulty of breathing 
lessens, the cough loosening, the voice gradually returning, the 



DISEASES OF THE LARYNX. 283 

fever, which has been more or less high during the attack, disap- 
pearing. 

If, instead of improvement, the case tends toward a fatal termina- 
tion, the suffocative attacks become more frequent, expectoration is 
absent, the voice and cough inaudible, although the efforts at speak- 
ing and coughing are visible, the difficulty of breathing continues, the 
respirations becoming more frequent and shallow, but without whist- 
ling and stridor, the cyanosis deepens, the countenance has an indif- 
ferent, drowsy, and stupid look, the eyes dull and nearly closed, with 
symptoms of depression, the pulse rapid and weak, the surface 
covered with a cold, clammy sweat, the extremities cold, stupor and 
insensibility more marked, the child dying of carbonic acid poisoning 
or asphyxia. 

Duration. The duration of true croup is about one week, rarely 
continuing ten days. 

Diagnosis. (Ede?na of the glottis might be mistaken for croup 
until the period of the formation of the characteristic membrane. 
The chief points of distinction from the onset are, however, absence 
of fever, paroxysmal attacks of difficult respiration, followed by a 
complete return to the normal condition. (Edema of the glottis is 
rare in childhood. 

The following are the chief points of difference between croup and 
laryngeal diphtheria : 

Croup. Diphtheria. 

A local disease. A constitutional disease. 

Begins in trachea and extends up. Begins at tonsils and extends down. 

Exudation never cutaneous. Exudation often cutaneous. 

No pain in swallowing. Often severe pain in swallowing. 

No swelling of submaxillary and Swelling of submaxillary and lymph- 
lymphatic glands. atic glands. 

Cough always present and often re- Seldom much cough and then only 
duced to a mere whistle with pecu- hoarse, 

liar metallic ring. 

Not traceable to bad drainage. Often traceable to bad drainage. 

Seldom occurs in adults. Often occurs in adults. 

Neither contagious nor infectious. Both contagious and infectious, both 

before and after death. 

A sthenic disease. An asthenic disease. 



284 PRACTICE OF MEDICINE. 

Croup. Diphtheria. 

Membrane does not extend to nares. Often extends to nares and many 

other parts. 
No symptoms of septicaemia. Septicaemia generally present. 

No albuminuria. Albuminuria frequent. 

Neither attended with nor followed Paralysis not uncommon. 

by paralysis. 
Death seldom caused by syncope. Death from syncope common. 

Death due to suffocation. Death frequently results from other 

causes. 
Absence of a specific germ. Presence of the Klebs-Loeflier bacillus. 

Prognosis. A very fatal disease. The danger increases in pro- 
portion to the age and feebleness of the child. Intubation has won- 
derfully lessened the mortality in croup. 

U?ifavorable symptoms are : Loud, stridulous, inspiratory, and expi- 
ratory sounds, laborious and prolonged expiration, depression of the 
base of the thorax during inspiration, whispering voice or complete 
aphonia, congestion of the face and neck, stupor, weak, rapid, and 
irregular pulse, cold extremities, and a cold, clammy perspiration. 

Favorable symptoms are : Expectoration of false membrane, de- 
crease of the stridulous respiration, voice changing from whispering 
to hoarseness, looseness of the cough, moderation of the fever, and 
an improvement in the general condition. 

Treatment. The i?idications for treatment are to detach and 
re?nove the false membrane, to prevent its reformation, to prevent the 
attacks of spasm of the glottis, and to maintain the strength. 

To detach and remove the membrane emetics are of the highest 
utility, the favorite of this class being the one first used in this disease 
by Dr. Fordyce Barker, consisting of hydrargyri subsulphas flavtis 
(turpeth mineral), gr. ij (0.13 Gm.) for a child of two years of age, 
repeating the dose as often as rendered necessary by the obstructed 
breathing; but the unnecessary administration of emetics should be 
avoided, as the strength of the patient must be maintained. 

To prevent the formation of the ?ne?nbranous exudation a number 
of remedies have been recommended and highly lauded, but hydrar- 
gyrum is the only one that has stood the test of experience ; it may 
be used as hydrargyri chloridum corrosivum, gr. ^V" 2V (0.0015-0.003 
Gm.) every two or three hours, or in the following formula : 



DISEASES OF THE LARYNX. 285 

R. Hydrargyri chloridi mitis, . . . gr. %-}£-}2, .008-.016-.032 Gm. 
Sodii bicarbonatis, ...... gr. ij. .13 Gm. 

Pulvis ipecacuanha;, gr. T V~ §- .005— .oil Gm. M. 

Sig. — One powder every two hours. 

Prof. Da Costa has suggested either of the following combinations : 

& . Antimonii sulphurati, gr. ^ .008 Gm. 

Pulv. ipecacuanha; et opii, . . . gr. y z .032 Gm. M. 

Sig. — In powder every two hours. 

Or— 

R. Hydrargyri chloridi mitis, . . . gr. ^ .008 Gm. 

Pulvis ipecacuanha; et opii, . . . gr. y^ .032 Gm. M. 

Sig — In powder every two hours. 

Antimonii et potassii tartras, a remedy that some years ago was 
popular in large doses, is again brought forward in doses of gr. 
"S^nV (0.002-0.003 Gm.). Quinines sulphas, gr. v. (0.3 Gm.) every 
three hours until six doses have been taken, if given before the 
exudation has formed, it is claimed will prevent its formation. It can 
be used by suppository. 

To prevent the paroxysms of spasm, small doses of opium in the 
form of pulvis ipecacuanha et opii (Dover's powder), or full doses 
of the bromides, preference being given to ammonii bromidum, as 
suggested by Prof. Bartholow, on account of its being " eliminated by 
the bronchial and faucial mucous membrane, thus acting locally." 

To maintain the strength of the patient, alcoholic stimulants in full 
doses, nutritious but easily digested alit?ient, strychnines sulphas in 
tonic doses, and ammonii carbonas, are particularly indicated. 

As soon as emesis has subsided, intubation should be practised. 

Locally, the use of all caustic or irritating applications to the fauces 
or larynx is emphatically contraindicated. 

The inhalation of the vapor of slaked, freshly burned lime is one 
of the most ready and efficient means for assisting in the detachment 
of the false membrane. The application cf cold or hot compresses, 
according to the feelings of the patient, around the throat, have a 
strong tendency to prevent the recurrence of the spasms. After the 
formation of the membrane, great relief follows the use of the vapor 
inhalations and of oxygen gas, which, with stimulants and liquid 
nourishment, may safely carry the patient through the disease. Cases 



286 PRACTICE OF MEDICINE. 

in which the membrane presents a tendency to slowly loosen itself, if 
the patient's strength does not contraindicate it, are greatly benefited 
by the application of sinapis, or even small flying-blisters, to the 
larynx. Inhalations of oxygen have seemed useful in several cases, 
as has the internal use of hydrogen dioxidum. 

Niemeyer advises, in cases showing carbonic acid poisoning from 
obstruction of respiration due to accumulation of membrane, the 
pouring from a moderate height of a few gallons of cold water over 
the head, nape, and back of the child ; the shock produced always 
causes it to revive for a while, and to cough vigorously, thus expecto- 
rating large quantities of the membrane, but this procedure will become 
obsolete in proportion as intubation is practised. 

If the exudation still continues, regardless of the means employed, 
the propriety of tracheotomy must be determined. 



LARYNGISMUS STRIDULUS. 

Synonyms. Spasm of the glottis ; pseudo-croup ; Millar's 
asthma ; thymic asthma : " Kopp's asthma" ; tetany. 

Definition. A spasm of the muscles of the larynx innervated by 
the inferior or recurrent laryngeal nerves ; characterized by a sudden 
development of dyspnoea and the appearance of deficient oxygena- 
tion of the blood. 

MacKenzie describes it as " a form of convulsion occurring in 
ill-nourished infants, characterized by spasmodic action of the abduc- 
tors of the vocal cords, and in severe cases by spasm of the diaphragm 
and intercostal muscles." 

Causes. Most common in children, the result of teething, laryn- 
gitis, indigestion, scrofula, or other cachexias. Attacks in adults are 
not uncommon. It is often hereditary. 

Pathological Anatomy. Death the result of spasm of the 
glottis is such a very rare occurrence that the changes in the larynx 
are not determined. 

The mechanism consists in an irritation of the superior laryngeal 
nerve, — the afferent nerve, — whose function is to supply the mucous 
lining of the larynx with sensibility, whence is reflected through the 
inferior laryngeal nerve — the efferent nerve — the motor influence 
resulting in the spasm of the laryngeal muscles. 






DISEASES OF THE LARYNX. 287 

Symptoms. The spasm of the laryngeal muscles is of sudden 
onset, and usually after nightfall. The child may have been in 
perfect health, to all appearances, on retiring, or it may have shown 
symptoms of catarrh of the upper air passages, or been suffering from 
gastro-intestinal or dental irritation. 

The child awakes suddenly, coughing in a metallic, resonant tone — 
the croupy cough — and with great dyspnoea, with lot/d, crowing, 
stridulous inspirations, the result of narrowing of the larynx from 
spasm, with wheezy, stridulous expirations. 

The entrance of air is so greatly obstructed that all the accessory 
muscles of respiration are called into use; the lips and finger nails 
become blue, the surface cold, the countenance anxious, and the 
inferior portion of the chest is drawn in, instead of being expanded, 
during inspiration. General convulsions occur at times, during a par- 
oxysm, also strabismus, and involuntary discharge of the faeces and 
the urine. 

The paroxysm continues from half an hour to an hour or more, to 
return after a few hours' sleep or during the following night ; the 
cough, during the day, having the croupy character. 

Diagnosis. The non-febrile and distinctly intermittent nature of 
the affection differentiates it from croup, and its own distinctive char- 
acters from all other diseases. The view is gaining that it is a 
variety of tetany. 

Prognosis. Favorable. Death from suffocation during the par- 
oxysm may occur in very young children, but it is certainly a very 
rare termination. 

Treatment. For the paroxysm, the inhalation of a few drops of 
chlorofor?nu?n is the most prompt method, care being exercised, as 
complete anaesthesia is unnecessary. Success is reported from the 
prompt inhalation of amylnitris, also from nilro-glycerinum, in small 
but frequently repeated doses. The following combination is a prompt 
antispasmodic : 

$. Potassii bromidi, 3 ij 8. Gm. 

Chloral, gr. xxxij 2. Gm. 

Syr. aurantii cort., f ^ j 30. Cc. 

Aquae menth., f^j 30. Cc. 

SlG. — One teaspoonful every half hour. 

After theparoxy-sm has been suspended by the above combination, 
the tendency to a recurrence of the attacks is prevented by the steady 



288 PRACTICE OF MEDICINE. 

and continued use of ftotassii bromidum, in moderate doses. Emetics 
are often useful in suspending an attack, especially if it be due to 
indigestion. 

Mackenzie advises the use of musk during the attack if the child 
can swallow ; and if not, then as soon as the child can take it, and 
continued at intervals for a day or two. His formula is as follows : 

R . Moschi, gr. iss .10 Gm. 

Sacch. alb., gr. ij .13 Gm. 

Pulv. acaciae, gr. ij .13 Gm. 

Syr. aurantii flor., 

Aquam, aa ad f gj aa 4. Cc. 

Sig. — A dose. 

The high price of musk, however, prohibits its general use. 

Locally, the hot, alternating with the cold pack, should be constantly 
applied to the throat. 

The air of the room should be moistened by the vapor of hot water 
constantly disengaged in it. 

After the attack has passed off, the general condition of the child 
requires attention ; for this purpose it is well to administer a dose of 
hydrargyri chloridum mite, to be followed by a dose of oleum ricini 
or magnesii carbonas. The diet must be regulated, all farinaceous 
articles being absolutely forbidden. 



TUBERCULOUS LARYNGITIS. 

Synonyms. Laryngeal phthisis ; throat consumption. 

Definition. An inflammation, tending to ulceration, of the tissues 
of the larynx, of tuberculous origin ; characterized by pain on deglu- 
tition, cough, weakness of voice, and progressive emaciation, asso- 
ciated with hectic fever. 

Causes. An infection of the larynx with the bacillus tuberculosis, 
either from the inspired air or by the sputum. A depressed state of 
the system is essential for the action of the bacilli. 

Pathological Anatomy. It is well to remember that all chronic 
inflammations of the larynx associated with pulmonary tuberculosis 
are not tubercular. 

Begins with redness of the mucous membrane, showing scattered 
tubercles. The tubercles show a strong tendency to cluster, then 






DISEASES OF THE LARYNX. 289 

soften, leaving shallow, irregular ulcers. The ulcers are covered with 
a grayish exudate. The mucous tissue round about the ulcers is 
thickened. The ulcers may, and generally do, erode the true vocal 
cords, often entirely destroying them. The ulcers slowly extend in 
all directions, destroying the tissues attacked. The epiglottis may be 
entirely destroyed. 

Symptoms. Usually develops secondary to pulmonary symp- 
toms ; rarely it may occur as a primary disease, to be followed with 
tuberculosis of the lungs. The first symptom is a change in the 
voice — huskiness ; this, associated with symptoms of ill health, is 
always a warning to the physician. The husky voice may proceed 
until it is but a painful whisper. Cough of an irritating, painful 
character associated with slight expectoration. Painful and difficult 
deglutition (dysphagia) is a very constant and distressing symptom. 
There is the remitting fever so characteristic of tuberculosis, with 
night sweats, loss of appetite, loss of flesh, and insomnia. 

Laryngoscopy examination reveals the characteristic broad, shal- 
low, irregular, grayish ulcers, with the thickened surrounding mucous 
membrane. The vocal cords show infiltration and thickening or 
ulceration. 

Diagnosis. To discriminate from non-tubercular laryngitis, ex- 
amine the sputum, and if the specific bacilli are found, the diagnosis 
is conclusive. 

Prognosis. Unfavorable. 

Treatment. Remember that tubercular laryngitis is not always 
preceded by pulmonary phthisis, but in a fair proportion of cases is a 
primary disease. Much can be done to make the patient comfort- 
able. The application of twenty, forty, or even sixty per centum 
solution of acidum lacticum is a very successful remedy. Cocaines 
hydrochloras applied directly to the ulcers gives relief to the pain and 
dysphagia. Local applications of hydrogen dioxidum, argenti nitras, 
and menthol are of value. Curetting the ulcers and applying iodo- 
formum in emulsion or with morphines sulphas has been practised 
with benefit. 

The general condition must be treated, the diet liquid and of a most 
nourishing- character. 



2^ 



290 PRACTICE OF MEDICINE. 



DISEASES OF THE BRONCHIAL TUBES. 



ACUTE BRONCHITIS. 

Synonyms. Bronchial catarrh ; acute bronchial catarrh ; "cold 
on the chest." 

Definition. An acute catarrhal inflammation of the bronchial 
tubes of the larger, middle, and third size ; characterized by fever, 
substernal pain, a feeling of thoracic constriction, oppression in 
breathing, and at first scanty, followed by more or less profuse, 
expectoration. 

Causes. Most frequent in childhood, especially during the period 
of dentition, when there exists a strong tendency to catarrh of the 
mucous membranes in general and of the bronchi in particular. In 
old age the predisposition again returns. Inhalations of irritants such 
as dust, smoke, and air too hot or too cold. More common in cli- 
mates characterized by considerable moisture of the atmosphere, 
combined with a low temperature, and especially where there are 
sudden and marked variations. A specific germ ? 

Pathological Anatomy. Hyperamia of the mucous mem- 
brane of the bronchial tubes, manifested by a diffused redness, swell- 
ing, oede77ia t and diminished secretio?i, followed by an increased 
secretio7i and overgrowth and desquamation of the epithelial cells, 
together with a copious generation of young cells, the expectoration 
then becoming of a yellowish color (muco-purulent). As a result of 
the hyperemia, rupture of the capillaries of the mucous membrane 
frequently occurs, when the slight expectoration of the first stage is 
streaked with blood. 

In cases of bronchitis following the exanthemata, or in scrofulous 
patients, the bronchial glands participate in the inflammation, 
becoming hypersemic, swollen, and filled with secretion, and not 
infrequently the glandular elements undergo a hyperplasia, and 
finally the " cheesy " degeneration. 

Symptoms. The invasion is usually characterized by the occur- 
rence of either nasal or laryngeal catarrh, or both, the patient feeling 



DISEASES OF THE BRONCHIAL TUBES. 291 

chilly, followed by flushes of heat; the limbs, joints, and even the 
body, are affected with pain of an aching, contused character, and 
with a sense of fatigue and want of energy ; there may be a furred 
tongue, anorexia, and constipation. 

In nervous, irritable persons, and in children, there may be slight 
delirium, and often in very young children, especially during the 
period of dentition, convulsions may usher in an attack. 

After a day or two of these initiatory symptoms, those characteristic 
of bronchial catarrh develop. 

Pain is experienced be7ieath the sternum, especially toward its upper 
part, of a raw, burning, or tearing character, aggravated by a deep 
inspiration or by coughing ; the pain also radiates toward the sides, 
following the course of the primary bronchial tubes. Tenderness 
over the sternum is often experienced. Muscular pain and tender- 
ness of rheumatic character are often associated with attacks of bron- 
chitis. 

Cough from the onset, at first in paroxysms of a hard, dry character, 
changing as the disease progresses, and becoming looser, followed 
by free expectoration. The expectoration at first is small in quantity, 
almost transparent, frothy, and having a salty taste, often streaked 
with blood. As the disease progresses it becomes more abundant, 
of a yellowish or a greenish-yellow color, and of a tenacious con- 
sistency. 

There are present slight fever, hot, dry skin, frequent pulse, loss of 
appetite, moderate thirst, and constipation. 

A feeling of languor and weariness, and often considerable de- 
pression, quite out of proportion to the febrile state, are not in- 
frequent. 

Percussion. Nortnal, except in those rare cases in which the 
bronchial glands are involved, when irregular spots of dullness can 
be developed. 

Auscultation. First Stage : The bronchial membrane being 
swollen and dry, the respiratory murmur is harsh or vesiculobronchial 
in character, associated with diffused sonorous and sibilant rales. 

Second Stage : The secretion from the bronchial mucous membrane 
being increased, the respiratory murmur is less harsh in character, 
but is associated with large a?id small moist or bubbling rales. 

Diagnosis. The points of resemblance and difference between 
acute bronchitis and other diseases of the chest will be pointed out 



292 PRACTICE OF MEDICINE. 

when those affections are described. The association of bronchitis 
with other diseases must not be forgotten. 

Prognosis. Acute bronchitis of the larger tubes usually termi- 
nates in complete resolution within two weeks. In children and in the 
aged the course is more protracted, and the symptoms more severe, 
but recovery is the rule. Very aged and feeble persons may succumb, 
but it is rare. 

Treatment. Depends upon the stage when seen. During the 
invasion, quinince sulphas, gr. x (0.6 Gm.), combined with ?norphiti(Z 
sulph., gr. l /e (0.0 1 1 Gm.), will usually prevent or abort an attack of 
acute bronchitis. 

In the first stage, in adults, when the mucous membrane is swollen 
and dry, either of the following prescriptions will give prompt relief: 

& . Antimonii et potassii tart., . . . gr. ij .13 Gm. 

Liquor, ammonii acetatis, . . . fjiv 120. Cc. 

Spts. Ktheris nitrosi, f IJjj 30. Cc. 

(Tinct. aconiti, if indicated), . . f^ss 2. Cc. 

Syr. simplicis, adf^vj ad 180. Cc. M. 

Sig. — Two teaspoonfuls every two or three hours. 

Or— 

R . Vini ipecacuanhae, fsrj 4. Cc. 

Liq. potassii citrat., f 3 iij 90. Cc. 

Liq. ammonii acetat., foMJ 9°- ^ c - ^* 

SlG. — Tablespoonful every two or three hours. 

If the cough of the dry stage be severe, or if the looseness of the 
bowels follow the use of either of the above combinations, tinctura 
opii camphorata may be added with advantage, or codeina, but use 
opium, with caution, in the dry stage. Tinctura hyoscya?ni, rr\,v-xv 
0.3-1 Cc.) is much better. 

For young children the above, in proportionately reduced doses, or 
the following : 

R. Pulv. ipecac, et opii, gr. v .3 Gm. 

Pulv. scillae, gr. x .6 Gm. 

Hydrargyri chlor. mitis, .... gr. ij .13 Gm. 

Sacch. lack, gr. x .6 Gm. M. 

Ft. chart. No. x. 

SlG. — One every two hours. 



DISEASES OF THE BRONCHIAL TUBES. 293 

The following is an excellent mixture for children : 

R. Potassii citrat. , 3 ij 8. Gm. 

Syr. ipecac, f^ij 8. Cc. 

Syr. scillae, f t ^j 4. Cc. 

Syr. limonis, f^ij 8. Cc. 

Tinct. opii camphorat., f^ij 8. Cc. 

Elix. simplicis, adf^iij ad 90. Cc. M. 

SiG. — Teaspoonful every couple hours. 

Locally : Hot mustard foot bath, and sinapis or terebinthina stupes 
over the chest, or, if much substernal pain and sthenic, a few dry or 
even wet cups, the patient being confined to an apartment in which 
the air is moistened by the vapor of hot water. 

Second Stage : The secretion of the bronchial mucous membrane 
being copious, stimulating expectorants are indicated, such as ammonii 
chloridum, scilla, a?n?nonii carbonas, or potassii carbonas. A reliable 
combination is: 

R. Ammonii chloridi, 31J 8. Gm. 

Scillse aceti, f 3 iij 12. Cc. 

Syr. ipecac, fgij 8. Cc. 

Misturse glycyrrhizae comp., . ad f^iij ad 90. Cc. 
SiG. — Dessertspoonful every three hours. 

Attacks showing a tendency to linger are greatly benefited by the 
following : 

R . Terebeni, f 3 ij 8. Cc. 

Creosoti, TTixxiv 1.5 Cc. 

Mucil. acaciae, q. s. q. s. 

Aquae chloroformi, .... ad f^ iij ad 90. Cc. M. 

SiG. — One teaspoonful every four hours, diluted. 

During the attack, attention must be given to the secretions and to 
the diet of the patient. During convalescence a course of strychninae 
sulphas or tinctura nucis vomicae is valuable. 



CAPILLARY BRONCHITIS. 

Synonyms. Broncho-pneumonia (?) ; "suffocative catarrh." 
Definition. An acute catarrhal inflammation of the mucous 
membrane of the terminal bronchial tubes, or bronchioles ; charac- 
terized by fever, impeded and increased respiration, impeded circula- 



294 PRACTICE OF MEDICINE. 

tion, slight cough and scanty expectoration, and symptoms of non- 
aeration of the blood. 

Causes. Most common in childhood, following exposure to cold 
or sudden changes of temperature ; occurs also in the aged, and also 
complicates measles, whooping cough, or any of the debilitating dis- 
eases. There may be a special germ. 

Pathological Anatomy. Hyperemia, redness and swelling of 
the lining membrane of the bronchioles, with the exudation of a 
tough, tenacious secretion. 

In those cases in which the air cells are not involved the air passes, 
during the act of inspiration, through the secretion blocking the 
smaller tubes, but is prevented from escaping during the act of 
expiration, the secretion in the smaller tubes acting as a valve ; the 
result is distention of numerous vesicles, producing a circumscribed 
or diffused functional emphysema. If the secretion produces com- 
plete closure of any of the smaller tubes, the air previously drawn 
into the vesicles will be absorbed, causing pulmonary collapse 
(atelectasis). 

If the inflammation extends to the alveoli of the lungs, it produces 
the condition known as bro?icho-pneu?no?iia, a frequent complication 
in children and feeble elderly people ; it is most commonly lobular 
in character, whence the term " lobular pneumonia" 

Symptoms. Usually preceded by more or less ordinary bron- 
chitis, followed by rise of temperature, 102-103 F., increased pulse, 
difficult and increased respiration, numbering forty, fifty, or sixty in 
the minute, with paroxysms in which the dyspnoea is markedly aggra- 
vated, when cyanosis rapidly develops ; the tongue is coated, bowels 
costive, appetite impaired, and there is restlessness and headache. 

The circulation through the lungs is impeded by the dyspnoea, the 
pulse becomes feeble and flickering, and there results general con- 
gestion of the venous system, the countenance becomes livid, the lips 
and nails blue, the surface cold, and often covered with a c/ammy 
perspiration, the mind dull, and in children stupor and convulsions 
rapidly supervene, the result of the non-aeration of the blood. The 
cough is slight, but of a suppressed character, the expectoratio7i scanty, 
the patient usually swallowing the sputum. When cyanosis occurs, 
the cough may almost entirely cease ; expectoration also ceases, death 
soon following from apna?a d.nd depression. 

Percussion. Normal, except over those portions of the lungs (a 






DISEASES OF THE BRONCHIAL TUBES. 295 

bilateral disease) which are in a condition of col/apse, when dullness, 
rapidly develops and may as rapidly disappear, changing to other 
portions of the lungs — shifting dullness. 

Auscultation. First stage, a feeble, but high-pitched, respira- 
tory murmur, becomes less distinct and harsh as the disease progresses. 
The rales in the first stage are fine whistling, sibilant, changing in 
the second stage to fine bubbling or subcrepitant rales. The respira- 
tory murmur is absent over the dull area. 

Diagnosis. There is one point characteristic of capillary bron- 
chitis — it is a general or bilateral disease. Capillary bronchitis is 
often mistaken for true catarrhal pneumonia, the points of distinction 
between which will be pointed out when discussing the latter affection. 

Prognosis. In children, on account of their inability to expec- 
torate, which, tends to rapid collapse of the lungs, and in the aged, 
the prognosis is most grave. In the strong and vigorous, recovery 
follows prompt and energetic treatment. 

Treatment. From the very onset of the attack the treatment 
must be supporting, with the addition of such measures as seem to 
possess a controlling influence over the catarrhal process. 

The patient must be confined to bed, well covered, and the tem- 
perature of the room varying between 75 and 8o°, the air moistened 
with steam, or adding one or two teaspoonfuls of tinctura benzoin 
to the hot water. In the first stage dry cups, mild sinapis applications, 
or terebinthina stupes should be applied to the chest, after which it 
should be covered with an oil-silk jacket or a cotton jacket. 

The diet must be of the most nutritious character, the great aim 
being to sustain the powers of life until the catarrhal process has 
passed through the different stages ; hence milk, eggs, chicken, mut- 
ton and beef broths, with the free use of stimulants, commenced early 
and in amounts large enough to overcome the signs of depression 
which are present early in the attack. 

Unless the fever be high, 102 F., and continues, it need not be 
treated, but if it continues at that point or higher, a few doses of 
acetanilidum, gr. ij-iv (o. 13-0.26 Gm.), in brandy or whiskey, may be 
used. If the urine be scanty, use spiritus aetheris nitrosi. 

If suffocation be imminent, the cautious use of emetics may be indi- 
cated; the most suitable are ipecacuanha and hydrargyri sub sulphas 
flavus, or the hypodermic use of apomorphbia, gr. ^ (0.003 Gm.). 
Do not repeat emesis often enough to produce exhaustion. 



296 PRACTICE OF MEDICINE. 

For the catarrhal process two remedies are of inestimable value: 
one, potassii iodidum or ajnmonii iodidum, gr. j-ij (0.065-0,13 Gm.) 
for a child every hour or two, and gr. v-x (0.3-0.6 Gm.) for an adult, 
its action being to liquefy or thin the tenacious secretion and modify 
the inflammatory action ; the other is ammoiiii carbonas, gr. j-ij 
(0.065-0.13 Gm.) for a child every hour or two, and gr. v-x (0.3-0.6 
Gm.) for an adult. The two combined, but for the taste, make a 
valuable prescription : 

R. Potassii iodidi, . . , gr. ij .13 Gm. 

Ammonii carbonat., ...... gr. iij .2 Gm. 

Syr. glycyrrh., fo ss 2 - Cc. 

Syr. tolu, f3 ss 2 - Cc. 

Sig. — Every two or three hours. 

Excellent results have been obtained in the children's wards of the 
Philadelphia Hospital from the systematic inhalation of oxygen. 
Prof. H. C. Wood, in desperate cases of suffocative catarrh, advises 
the alternate use of the hot and cold douche conjointly with stimu- 
lating remedies. 



FIBRINOUS BRONCHITIS. 

Synonyms. Membranous bronchitis ; plastic bronchitis ; diph- 
theritic bronchitis ; croupous bronchitis. 

Definition. An acute inflammation of the mucous membrane of 
the larger and middle-sized bronchial tubes, attended with an exuda- 
tion, forming a membraniform layer, which is closely adherent to the 
mucous surface ; characterized by febrile reaction, cough, difficult 
breathing, scanty expectoration, followed by the expulsion of the 
false membrane in the form of patches or casts. 

Causes. Unknown; associated with membranous laryngitis from 
extension downward; asthma; emphysema; phthisis; frequently 
result of exposure to cold or damp, in those of feeble health or in 
tuberculous (?) constitutions. 

Pathological Anatomy. Hyperemia of the mucous mem- 
brane of the bronchial tubes, associated with swelling and oedema, 
during which the surface is covered with a whitish or grayish-white, 
firmly adherent, membranous deposit, cemented together by a coagu- 
lable exudation, and prolonged by rootlets from its under surface into 



DISEASES OF THE BRONCHIAL TUBES. 297 

the bronchial follicles, which sooner or later is loosened and detached 
by suppurative process, and is expectorated after a violent fit of 
coughing or vomiting. When expectorated, the false membrane, as it 
has been termed, has either the form of patches or is thrown off en- 
tire from the bronchial tube, and may be found to consist of casts 
representing more or less of the bronchial subdivisions, and present- 
ing an appearance not unlike " boiled macaroni." 

On microscopical examination, the detached membrane presents 
fibrillae which characterize fibrin or lymph in other situations ; and if 
placed in a solution of acetic acid, it becomes greatly swollen, while 
ordinary mucus contracts and becomes more dense if added to the 
same solution. 

Symptoms. There are no symptoms or signs by means of which 
this variety of bronchitis can be distinguished from ordinary catarrhal 
bronchitis, prior to the expectoration of the false membrane . 

Expectoration is preceded and accompanied by violent paroxysms 
of coughing, and after more or less of the membrane has been raised, 
a muco-purulent expectoration, streaked with blood, may be present 
for several days. 

Duration. The inflammation may be either acute, subacute, or 
chronic, expectoration of patches or strips of the membrane being 
repeated at intervals of days, weeks, months, or even years. 

Prognosis. In adults, favorable, if not associated with other 
grave affections, such as phthisis, pneumonia, emphysema. In 
young children it may cause obstruction to the respiration, and not 
infrequently proves fatal. 

Treatment. As the character of the inflammation can seldom 
be determined until the membrane or portions of it have been expec- 
torated, the treatment is at first the same as in attacks of ordinary 
acute bronchitis. 

As soon, however, as the character of the inflammation can be de- 
termined, active emesis is the most effective means of removing the 
obstruction caused by the false membrane, the best agents of this 
class being either hydrargyri subsulphas flavus, aPo?norphina, ipecac- 
uanha, or zinci sulphas, to be repeated as indicated. 

Inhalations of solutions of ammonii chloridum, pix liquida, euca- 
lyptol, or simply the vapor of water, and especially of lime-water, 
are highly serviceable. 

To prevent the formation of membrane, Prof. Bartholow strongly 
26 



298 PRACTICE OF MEDICINE. 

urges the use of ammoniiiodidum and a?n?nonii carbonas combined, 
in small doses, every hour or two. In a case treated by the author 
after this method, excellent results followed. Potassii iodidum is also 
useful. 

In cases showing a tendency to become chronic, good results 
will follow the application of flying blisters to the eldest and the 
internal administration of arsenicum and some preparation of pix 
liquida. 

CHRONIC BRONCHITIS. 

Synonyms. Chronic bronchial catarrh ; winter cough ; second- 
ary bronchitis. 

Definition. A chronic inflammation of the mucous membrane of 
the larger and middle-sized bronchial tubes ; characterized by cough 
and more or less profuse expectoration, plus, in many cases, the 
symptoms of e?nphysema of the lungs, which is a frequent complica- 
tion. 

Chronic bronchitis may be either primary or secondary. 

Causes. Primary, exposure to wet or cold, or the repeated inha- 
lation of dust, vapors, or other irritants. Secondary, gout, rheuma- 
tism, syphilis ; cardiac, renal, or pulmonary diseases, or alcoholism. 

Varieties. • I. Mucous catarrh, associated with moderate expec- 
toration. II. Bronchorrhcea, profuse expectoration. III. Dry catarrh, 
scanty expectoration. IV. Fetid bronchitis. V. Bronchiectasis, or 
dilatation of the bronchi. 

Pathological Anatomy. The mucous membrane of the bron- 
chial tube is discolored, being of a more or less dull red, often of a 
deeply venous hue, mingled with a grayish or brownish color. These 
changes may be either in patches or extensively diffused. The ves- 
sels of the mucous membrane are dilated. The mucous membrane 
is thickened, resulting in reduction in the calibre of the tube and 
a roughening of its internal surface. The submucous tissue becomes 
infiltrated, contracted, and indurated. 

The elastic and muscular coats of the tubes become hypertrophied, 
lose their elasticity, and the cartilages become the seat of calcareous 
deposits. 

As the result of the loss of elasticity and muscular tone of the tubes 
they become irregularly dilated — " bronchial dilatation." The dilata- 



DISEASES OF THE BRONCHIAL TUBES. 299 

tions may be uniform in character, resembling somewhat the fingers 
of a glove, or they may be sacculated or globular, forming actual 
cavities in the bronchial structure. 

In the mucous variety the secretion consists of young cells and 
mucous corpuscles, having a yellowish color ; in the dry variety, the 
"catarrhe sec" of Laennec, or "dry bronchial irritation," the secre- 
tion is scanty, tough, semi-transparent, and occurs in globular 
masses ; in bronchorrhosa, which is usually associated with bronchial 
dilatation, the secretion is abundant, greenish-yellow in color, and 
frequently fetid. 

The majority of cases of chronic bronchitis are associated with 
chronic gastric catarrh. 

Symptoms. The most characteristic symptoms of chronic bron- 
chitis are the cough and expectoration. The cough occurs at all hours, 
but is more severe at night and early in the morning. The cough is 
not always present. It disappears almost altogether for a time, and 
then reappears, continuing thus for years. Coated tongue, disagree- 
able taste, loss of appetite, impaired digestion, with eructations of 
gases, are present in many cases, due to the chronic gastric catarrh. 
Unless associated with other diseases, the general health suffers but 
little, if at all, constitutional symptoms being present only during 
acute exacerbations. 

Mucous catarrh, or, from its occurring most commonly during the 
winter months, "winter cough," is characterized by paroxysms of 
cough, more or less violent, followed by the expectoration of a yellow- 
ish mucus. 

Dry catarrh is characterized by a harsh cough, a feeling of soreness 
or rawness under the sternum, and the expectoration of small globu- 
lar masses ; this variety occurs with emphysema, gout, rheumatism, 
and asthma. 

Bronchorrhcea, which is associated with bronchial dilatation, and 
most common in the elderly, is characterized by paroxysms of severe 
coughing, followed by the copious expectoration of greenish-yellow, 
often fetid, mucus ; the amount expectorated often amounts to four 
or five pints in the twenty-four hours. 

Fetid bronchitis, often associated with bronchial dilatation, has an 
excessively fetid odor of the breath and expectoration. The decom- 
position of the secretion may cause gangrene of the bronchial mucous 
membrane, and even of the lun£ structure. 



300 PRACTICE OF MEDICINE. 

Percussion. Unless complicated with other affections, normal ; 
if bronchial dilatation occur, there are diffused spots of the tympanitic 
or ajnphoric percussion sound, the physical condition being a circum- 
scribed cavity containing air and communicating with a bronchial 
tube. 

Auscultation. Harsh or vesiculobronchial respiration, asso- 
ciated with more or less profuse, sonorous, sibilant, and large and 
small bubbling rales ; in bronchial dilatation, in addition to the harsh 
respiration, is found broncho-cavernous breathing, with large and 
small gurgling rales. 

If emphysema complicate chronic bronchitis, the physical signs are 
somewhat modified, and will be pointed out when discussing that 
affection. 

Diagnosis. Always examine the urine in case of cough, and 
particularly in chronic bronchitis, as this disease is one of the most 
frequent complications of Bright's disease. 

Incipient phthisis is often confounded with chronic bronchitis. The 
diagnosis is not always easy. The physical signs of chronic bron- 
chitis are more or less diffused through both lungs, and not, as a rule, 
associated with failure of the general health ; while in phthisis, from 
the onset, there is failing health, with a concentration of the physical 
signs to the apices. The discovery of the bacillus determines the 
diagnosis. 

Prognosis. If unassociated with disease of the lungs, heart, or 
kidneys, chronic bronchitis is never dangerous to life, although the 
symptoms are present, more or less, continually, and aggravated 
upon the least exposure. Rarely is a complete cure recorded. 

If associated with phthisis, emphysema, diseases of the heart or of 
the kidneys, the prognosis is governed by these affections. In turn, 
it is to be remembered that chronic bronchial catarrh may lead to 
emphysema of the lungs, asthma, or to cardiac dilatation. 

Treatment. Cases of chronic bronchitis, of whatever variety, 
should observe the following general rules: I. Attention to the gen- 
eral health. 2. The clothing; wearing flannel the year round, or, 
what is better, silk underclothing, avoiding the opposite extreme 
of excessive clothing. 

The fnedical treatments guided by the cause, character, and severity 
of the disease. 

If secondary to other affections, in the majority of cases remedies 



DISEASES OF THE BRONCHIAL TUBES- 301 

directed to the bronchial mucous membrane are contra-indicated. 
If the result of the rheumatic or gouty diathesis, in addition to the 
remedies directed to the disease itself, should be combined change 
to a warm climate, if possible, and a more or less protracted course 
of potassii iodidum, or lithii citras, or a residence at one of the alka- 
line springs. 

If associated with alcoholism or chronic gastric catarrh, the follow- 
ing is a valuable combination : 

R . Ammonii chloridi, ppij 12. Gm. 

Tinct. nacis vomicae, fgij 8. Cc. 

Infus. gentianse comp., . q. s. ad f^iv ad 120. Cc. M. 

SiG. — Dessertspoonful in water before meals. 

For mucous catarrh with acute exacerbations : 

R. Ammonii chloridi, £ij 8. Gm. 

Glycerini, f^iss 45. Cc. 

Codeinae sulph., gr. j .065 Gm. 

Vini picis liq., f.^iij 9°- Cc. 

Syr. prun. virg., f^iss 45- Cc. M. 

SiG. — Tablespoonful every three or four hours. 

Dry catarrh is greatly benefited by — 

R. Potassii iodidi, - . gr. v-x .3~.6 Gm. 

Elix. cinchonas, ti\,xx 1.3 Cc. 

Vini picis liq., adf^ss ad 15. Cc. M. 

Three times a day. 

For an acute exacerbation of dry or tenacious chronic bronchitis : 

&. Ammonii chloridi, giv 15. Gm. 

Tinct. hyoscyam., f^iv I S- Cc. 

Syr. scillse comp., f,^i v J 5- Cc. 

Aq. chloroformi, f^ij 60. Cc. M. 

SiG. — One teaspoonful every three hours, diluted. 

An excellent expectorant combination in all forms and at any stage 
of bronchial catarrh is : 

R. Ammonii carbonat. , gr. xvj I. Gm. 

Ext. scillae fid., f£ ss 2. Cc. 

Ext. senegae fid., f£) ss 2 - Cc. 

Tinct. opii camphorat., .... fspij 12. Cc. 

Syr. tolu t f^iss 45. Cc. M. 

SiG. — Teaspoonful every few hours, diluted. 



302 PRACTICE OF MEDICINE. 

For bronchorrhcea, copaiba, Tt\,v-x (0.3-0.6 Cc), every three hours, 
or spts. terebinthin<z \ v\y (0.3 Cc), every four hours, or acidum car- 
bolicum, gr. ss (0.032 Gm.), four times a day, are excellent drugs, or — 

R. Terebeni, fgij 8. Cc. 

Creosoti, TTlxxx 2. Cc. 

Acacise, q. s. q. s. 

Aq. chloroformi, fj|j 30. Cc. 

Syr. prun. virg. , ad f^iij ad 90. Cc. M. 

SlG. — Teaspoonful every three or four hours, diluted. 

And at the same time using ol. morrhuce and arsenicum, or, if these 
means fail, inhalations of alumen, acidum gallicum, or acidum tan- 
nicum. 

If the expectoration be fetid, " fetid bronchitis," Prof. Da Costa 
recommends the internal use of acidum carbolicum, rt\j (0.06 Cc), 
every third hour, with inhalations of acidum carbolicum, gr. v (0.32 
Gm.), aquce, fgj (30 Cc), two or three times a day. Good results 
may also be obtained from the terebene and creosote mixture given 
above. 

If, after prolonged treatment, cure or great amelioration does not 
occur, then a change of climate is called for. Usually a warm climate 
is the most suitable, but sometimes a dry, bracing climate does 
better. 

Locally, irritation with ti?ictura iodi, or flying blisters, repeated once 
or twice weekly, is of advantage. 



ASTHMA. 

Synonyms. Bronchial asthma ; spasmodic asthma. 

Definition. A paroxysmal, spasmodic contraction of the mus- 
cular layer surrounding the smaller bronchial tubes, and perhaps 
associated with a tonic spasm of the diaphragm and more or less 
bronchial catarrh ; characterized by spasmodic attacks of distressing 
expiratory dyspnoea, continuing several hours, days, or weeks. 

Cause. A true neurosis of the respiratory apparatus. The result 
of peripheral or local disturbances in the nervous system. Chiefly 
hereditary. A family history of asthma, chorea, or epilepsy. It 
is sometimes of reflex origin, starting from diseases of the nasal 
mucous membrane, explaining the attacks due to the inhalation of 






DISEASES OF THE BRONCHIAL TUBES. 303 

various substances, as ipecac, turpentine, or irritating dusts. Climate. 
Some attacks may be due to a peculiar and characteristic disease of 
the bronchial mucous membrane — an "asthmatic bronchiolitis." 
Bronchitis; "peri-bronchitis"; emphysema; chronic cardiac disease; 
chronic gastric catarrh ; malarial toxaemia. 

Asthma is more common in men than in women, and may occur at 
any age. 

Pathological Anatomy. Unless a " peri-bronchitis," nothing 
purely distinctive. The changes of emphysema are common. 

Symptoms. The onset of a first attack of asthma is abrupt and 
sudden, the succeeding attacks being preceded by prodromes, which 
the individual rapidly learns to appreciate — to wit : coryza, bronchial 
irritation, thoracic constriction, marked dyspepsia, or the scanty pas- 
sage of pale, limpid urine, the " hysterical urine." 

The paroxysm begins, in the majority of instances, in the early 
morning hours or during the afternoon, with a. feeling of anguish 
and constriction in the chest and an intense desire for air. The 
breathing \s accompanied with loud wheezing, the face is flushed, at 
times even cyanosed and bathed in perspiration, the eyes staring, the 
eyeballs protrude, and the muscles of the neck become prominent as 
they aid in the effort for air. The dyspnoea soon becomes so severe 
that the inspiration is but a gasp, the lips are pallid, cyanosis deepens, 
and the patient feels as if death were impending. Owing to the 
tonic contraction of the smaller bronchi, the air drawn into the alveoli 
escapes imperfectly, resulting in the expiratory dyspnoea, the emphy- 
sematous chest, and the lowered position of the diaphragm. 

After some minutes or hours the respiration becomes easier, the 
air in the lungs changes, the cyanosis disappears, and gradually the 
paroxysm ceases, the patient feeling exhausted and the chest fatigued. 

During the paroxysm there is a short, dry cough, becoming looser 
as the attack subsides. ■ The sputum of asthma is unique. Early in 
the paroxysm it is raised with difficulty, and is in the form of rounded 
gelatinous masses (" pedes" of Laennec). If these pellets be care- 
fully examined, they will be found to consist of moulds of the smaller 
bronchi, and, under the microscope, show Leyden's crystals and 
Curschmann's spirals. After a day or two the sputum becomes 
mucopurulent, and the spirals and crystals are absent. 

The duration of an attack varies from one to many hours, or even 
days. Instead of single paroxysms, slight remissions may occur at 



304 PRACTICE OF MEDICINE. 

intervals of one, two, or three hours, to be followed by exacerbations 
lasting from four to six hours, continuing for a week or two, prevent- 
ing the patient lying down or taking food. 

Percussion. During the paroxysm, hyper resonance over both 
lungs, termed vesiculotympanitic, the "band-box tone" of Bam- 
berger, due to the retained air in the alveoli. 

Auscultation. First stage feeble or absent vesicular murmur, 
with prolonged expiration associated with loud wheezing, whistling, 
sibilant and sonorous rales ; as the paroxysm subsides, the vesicular 
breathing becomes more apparent and is associated with moist rales. 

Prognosis. In itself asthma is not fatal to life ; but if the parox- 
ysms are frequently repeated, there results either emphysema, cardiac 
dilatation with subsequent dropsy, or even cerebral hemorrhage. 

Attacks of asthma frequently occur as a complication in emphy- 
sema, chronic bronchitis, valvular diseases of the heart, and Bright's 
disease. 

Treatment. There are two indications to meet: the relief of the 
paroxysm, and to prevent its recurrence. 

To relieve the paroxysm, no medication is so effective as the hypo- 
dermic injection of morphines sulphas, gr. Yd-%. (0.011-0.016 Gm.), 
combined with atropine sulphas, gr. y^ (0.00065 Gm.). Chloral, gr. x 
(0.6 Gm.), repeated, where no heart complication exists, is often 
effective. Drinking strong, hot, black coffee is often serviceable. 
Caffeince citrata during or at the onset of a paroxysm, in doses of gr. 
iij-v (0.2-0.3 Gm.), hypodermically, or in a cachet or in solution, re- 
peated until bronchial spasm is relieved, is a valuable drug. Page 
strongly recommends sodii nitras : 

&. Pulv. sodii nitritis, gr. xxiv 1.6 Gm. 

Aquae, {\) 30. Cc. M. 

Sig. — Teaspoonful at once ; repeat in half an hour, once or twice if necessary. 

The following combination by hypodermic injection is often most 
successful in relieving an attack of asthma, and particularly if compli- 
cated with cardiac or nephritic disease, continuing the combination 
after relief, in pill form or solution at ordinary intervals for several 
days : 

& . Spirit, glonoini, mjj .12 Cc. 

Strychninae sulph., gr. -^ -0013 Gm. 

Morphina: sulph., gr. -^ .003 Gm. M. 

Sig. — Dose. 



DISEASES OF THE BRONCHIAL TUBES. 305 

Chloroformum , cether, or amy I nitris inhalations have been recom- 
mended,, and also the nauseant expectorants, lobelia, ipecac, and 
scilla. Ext. grindelicB fid., tt\,xx (1.3 Cc), repeated every two or 
three hours is sometimes useful. 

Dr. Pepper speaks highly of the following for the paroxysm : 

$ . Ammonii bromidi, £ij J}ij IO. Gm. 

Ammonii chloridi, ....... 3 iss 6. Gm. 

Tinct. lobelise, -. . . f sjiij 12. Cc. 

Spts. setheris comp. , f^j 30. Cc. 

Syr. acacise, q.s. fjiv ad 120. Cc. M. 

SiG. — Dessertspoonful in water every hour or two, diluted. 

After the use of many drugs I have finally come to depend upon 
potassii iodidum, gr.v-x (0.3-0.6 Gm.), every three hours, either alone 
or combined with tinciura belladomtce, tti,v (0.3 Cc), or nitro- 
glycerin, gr. ^tyo^rirtf (0.00032-0.00065 Gm.), to remove the catarrhal 
condition remaining after a paroxysm and to prevent a return. 

Another remedy that at times is successful is syrnpus acidi hydrio- 
dici, f^ss-f^ (2-4 Cc), every three or four hours, well diluted. 

Inhalations of the fumes of belladonna, stramonium, nitre-paper, 
chloroform, ethyl bromidum, or the use of various pastilles or cigar- 
ettes, are of immense benefit in many cases. A twenty per cent, solu- 
tion of menthol as an inhalation has been successful in some instances. 
Inhalations of oxygen have given excellent results in a number of 
cases. 

If an attack is impending, it may often be aborted by drinking freely 
of strong, black coffee, or by full doses of the bromides. 

To prevent the recurrence of the paroxysms, the general health 
must be cared for, and any suspected causes corrected. In all cases 
a thorough examination of the nasal mucous membrane should be 
made and any diseased condition found removed. If chronic bron- 
chitis be present, it should be persistently treated. 

Two remedies long continued frequently give good results: potassii 
iodidum in doses ranging from five to fifteen grains (0.3-1 Gm.), and 
arsenicum in small doses. 

Additional aids are systematic exercise short of fatigue, bathing, 
regulated diet, and, when possible, a change of climate. 



306 PRACTICE OF MEDICINE. 



HAY ASTHMA. 

Synonyms. Hay fever ; autumnal catarrh ; rose fever ; rose 
cold. 

Definition. An acute, specific, catarrhal inflammation of the 
upper air passages, extending to the bronchial tubes, associated with 
spasmodic contraction of their muscular layer, occurring at a par- 
ticular season of the year, characterized by coryza, croupy or wheezy 
cough, and difficult respiration. 

Causes. A predisposition, often hereditary, of the nervous system 
seems to be a strong etiological factor. 

Persons in whom the predisposition exists have attacks excited by 
the inhalation of the pollen of grasses, rye, corn, wheat, or roses. 

Pathological Anatomy. Hypertrophy of the inferior and 
middle turbinated bones ; a peculiar hyperesthesia of the mucous 
membrane covering the inferior and middle turbinated bones, the 
middle meatus, the floor of the nose, and that part of the septum 
below the limit of the olfactory membrane are frequently associated 
with the disease. 

Symptoms. Begins by irritation of the eyes, severe coryza, with 
sneezing ; a clear, watery, nasal discharge, and congested Eustachian 
tubes, rapidly extending to the larynx and bronchial tubes, when 
occurs a hoarse, croupy, and wheezing cough, and difficulty of breath- 
ing. The dyspnoea occurs in paroxysms, which are often as severe 
as those occurring during a regular asthmatic attack. There is mild 
depression of the nervous system in nearly all attacks. 

The paroxysms remit after a few days, returning again for several 
days or weeks, and again remitting, the bronchial catarrh persisting 
for a month or more. 

The constitutional symptoms are mild, unless complications occur. 

Complications. The affection may extend to the finer bronchial 
tubes (capillary bronchitis); congestion or oedema of the lungs and 
pneumonia are not infrequent. 

Duration. Unless a change of climate is resorted to, paroxysms 
of hay fever continue more or less severe for six, eight, or ten weeks 
of the year, each year the paroxysms growing more severe. 

Prognosis. The affection never proves fatal in itself, but one 
or more of the following sequelae may result, to wit: asthma, 



DISEASES OF THE BRONCHIAL TUBES. 307 

chronic bronchitis, or loss of the special sense of hearing or of 
smelling. 

Treatment. No specific, unless the hypertrophy of the turbin- 
ated bones be a constant condition, when their removal by the 
galvano-cautery would remove the liability to attacks. 

An attack of hay asthma is often prevented by a change of climate 
during the season of the year when the -attacks are most common, to 
wit: the early autumn. Any of the following locations may be 
selected — White Mountains, Catskills, Adirondacks, Rocky Moun- 
tains, or a sea voyage. 

Dr. W. C. Hollopeter reports wonderful success in over two hun- 
dred patients with the following plan of treatment : 

"For the last ten years I have used the ordinary Dobell's solution. This 
I thoroughly use in both nostrils, first by means of a hand-ball atomizer, after 
which, with a curved aluminum applicator, I very carefully swab the whole 
naso-pharynx. I scrub most carefully every portion of the mucous membrane, 
being sure to reach between the turbinated bones and all around and over 
every slight prominence. I then as carefully dry the membrane with clean 
cotton, and use freely blandine comp. (a mild solution of menthol in albolene), 
loosely plugging the nose for a few minutes to retain the oily application. 
Great stress is laid upon the thoroughness of the applicatien and the correction 
of any ills the patient may have." 

Attacks are sometimes aborted and always relieved by the applica- 
tion to the nares of tablets of cocaines hydrochloras, gr. l /e (o.oi i Gm.), 
or a four or six per centum solution, every few hours. On several 
occasions pulvis ipecacuanhcB et opii, gr. v (0.3 Gm.), ter die, has 
aborted a suspected attack, as has the following pill : 

R. Atropine sulph., gr. \ .012 Gm. 

Morphine sul ph., gr. \ .016 Gm. 

Strychnine sulph., gr. \ .008 Cm. 

Quininse muriat., gr. x .65 Gm. 

Sodii arseniat, gr. \ .oil Gm. M. 

Ft. pil. No. xxx. 

Sig. — One every hour until dryness, then two or three hours apart. 

Success has followed the use of quinines sulphas, gr. v (0.3 Gm.), 
three times a day, beginning one month before the expected 
paroxysm. 

Bartholow " has seen several cases benefited greatly " by a solution 
of quini7ia applied to the nares, as suggested by Helmholtz, "but to 
achieve success the application must be thorough and timely." 



308 PRACTICE OF MEDICINE. 

The following applied thoroughly to the nostrils has a high repute : 

R. Menthol, gj 4. Gm. 

Cerat. simpl., 5jij 60. Gm. 

Ol. amygd. dulcis, f^i ss 45- Cc. 

Zinci oxidi purse, gj 4. Gm. 

Acid, carbolici, 3 ss 2. Gm. 

SiG. — Apply every two hours. 

A long course of arsenicum in minute doses sometimes removes 
the susceptibility to the disease. 



WHOOPING COUGH. % 

Synonyms. Hooping cough ; pertussis. 

Definition. A convulsive, paroxysmal cough, consisting of a 
number of forcible expirations, followed by a series of deep, loud, 
sonorous inspirations (the whoop), repeated several times during each 
paroxysm, and associated with catarrh of the bronchial tubes. 

Causes. Chiefly a disease of childhood, and fully one-half of 
the cases are during the first two years of life, one attack generally 
removing the susceptibility ; contagious ; due to an unknown micro- 
organism. 

Pathology. The changes, if any, occurring in the nervous sys- 
tem are unknown. It is said that "irritation of the internal branch 
of the superior laryngeal nerve produces relaxation of the diaphragm, 
spasm of the glottis, and a convulsive expiration, the series of phe- 
nomena present in a paroxysm of asthma." 

Hypercemia of the mucous membrane of the nares, pharynx, larynx, 
and bronchial tubes, with diminished secretion, followed by an in- 
creased secretion of a transparent mucus, afterward becoming puru- 
lent, the mucous membrane pale and anaemic. 

Symptoms. Divided into three stages, to wit: catarrhal, spas- 
modic, and terminal. 

Catarrhal stage originates in an ordinary naso-laryngo-bronchial 
catarrh, with a loose cough. Duration^ one or two weeks. 

Spasmodic Stage : The cough becomes ftaroxysmal, consisting of 
a succession of short, rapid, expiratory efforts, the face becoming red, 
the eyes swollen and protruding, the body bending forward, and when 
these expiratory efforts have exhausted the breath, they are followed 



DISEASES OF THE BRONCHIAL TUBES. 309 

by a deep, loud, crowing inspiration — the whoop : each paroxysm 
being composed of three such spells, the last one followed by the 
expectoration of a small amount of tough, viscid mucus. 

The attacks of cough may be so severe as to cause vomiting, and 
if the vomiting occur shortly after food has been taken, the nutrition 
of the patient will suffer. Profuse epistaxis is not infrequent. Dura- 
Hon, about four weeks. 

Terminal Stage : The paroxysms recur at longer intervals, are of 
shorter duration and less intensity, the catarrhal symptoms being 
more marked, the expectoration freer. Duration, one or two weeks, 
often followed by the " cough of habit." 

Complications. Congestion of the lungs, capillary bronchitis, 
pneumonia, and emphysema, or, rarely, convulsions, hydrocephalus, 
or apoplexy. 

Diagnosis. During the catarrhal stage whooping cough cannot 
be distinguished from a common cold, but on the advent of the char- 
acteristic whoop, the diagnosis is determined. 

Prognosis. Depends upon the age and strength of the patient, 
the severity of the paroxysms, and the presence or absence of com- 
plications. Ordinary cases, favorable. Moderately severe attacks 
during infancy are. followed by cerebral symptoms, while attacks 
occurring in adults are followed by chest symptoms. 

Treatment. No specific. A self-limited disease. Remedies will 
not cure the disease, but often lessen the duration of or modify the 
severity of the symptoms. Always watch the heart's action. 

Prof. Da Costa prefers quinine sulphas in full doses, or chloral 'in 
good-sized doses, often advantageously combined with the bromides, 
and the use of a spray of sodii bromidum, gr. xx (1.3 Gm.), and aquae, 
*oJ (30 Cc), to which may be added extractwn belladonna fluidum, 
tt\jj (0.12 Cc). A remedy of great utility is ammonii bromidum. 
Excellent results have followed the use of antipyrin gr. %-v (0.01 1- 
0.3 Gm.), or acetanilidum, gr. j-iij (0.065-0.2 Gm.), every four hours, 
according to the age, or phenacetin, gr. j-ij (0.065-0.13 Gm.), four 
times daily. Either of these drugs seems to act better if given with 
an expectorant. L. Emmett Holt recommends antipyrin, gr. j (0.065 
Gm.), every three hours for child six months old. Terpini hydras, 
gr. j-ij-v (0.065-0.13-0.3 Gm.), is sometimes valuable. Belladonna 
may be added to any of the remedies named with advantage, or 
the tincture may be used alone in doses of it\,v-x (0.3-0.6 Cc.) three 



310 PRACTICE OF MEDICINE. 

times daily until flushing of the surface, and a dose continued that 
maintains the flushing. 

Starr recommends the following for a child of one year: 

1£ . Ext. belladonna, gr. j .065 Gm. 

Aluminis, g ss 2. Gm. 

Syr. zingiberis, 
Syr. acacioe, 

Aquae, aaf^j aa 30. Cc. M. 

Sic — A teaspoonful four times in the twenty-four hours. 

Inhalations of creosote are very valuable, dropped upon cotton in 
a respirator, or vaporized over an alcoholic lamp, or cloths dipped 
in solutions may be hung in the room. Eucalyptol is also a valuable 
remedy for inhalation. 

The diet of the patient must be regulated, the clothing to he warm 
but not too heavy, and the patient kept in the open air as long as 
possible. 



EMPHYSEMA. 

Synonym. Vesicular emphysema. 

Definition. Dilatation of or increase in the size and capacity of 
the air vesicles, characterized by enlargement or distention of the 
lungs, difficulty of breathing, especially on exertion, and associated 
sooner or later with dilatation of the heart. 

Causes. The predisposing cause of emphysema is a hereditary 
nutritive derangement of the lung structure, often associated with a 
rigid enlargement of the thorax. 

The exciting cause is the result either of a too forcible and long 
continued inspiration, — the theory of inspiration, — or the excessive 
mechanical distention of the vesicular walls by forced expiration — 
the theory of expiratioti. But for either of these theories to be 
operative the lung structure must be congenitally weak, for if violent 
respiratory efforts alone were the essential factor, the disease would 
be much more frequent. 

What is known as vicarious emphysema is a distention of the air 
cells of the healthy portion of the lung, some other part being the 
seat of consolidation. 

Interlobular emphysema is the presence of air in the spaces between 
the lobules of the lungs underneath the pulmonary pleura. 



DISEASES OF THE BRONCHIAL TUBES. 311 

Pathological Anatomy. The situation of vesicular emphy- 
sema is, in the majority of cases, the superior portions of the chest, 
and is more marked on the left side than on the right. 

An emphysematous lung feels remarkably soft to the touch, and 
upon cutting a dull, creaking sound is barely perceptible. It is of a pale- 
red color; the vesicular walls are thinner and slighter ; the vesicles 
are greatly enlarged, sometimes to the size of a pea or bean, and have 
an irregular shape, and traversing most of these large sacs (dilated 
vesicles) a few delicate bands, the remains of the lacerated inter- 
alveolar septa, are visible. With the destruction of the septa many of 
the capillaries are destroyed, leaving the emphysematous tissue 
remarkably bloodless and dry. 

In consequence of the destruction of so many of the capillaries 
the obstruction to the pulmonary circulation becomes so great that 
the pulmonary artery and right cavities of the heart are greatly dis- 
tended ; finally the muscular tissue of the heart undergoes granular, 
followed by fatty, degeneration. The distention of the veins results 
in a general venous stasis, to wit : nutmeg liver, congested kidneys, 
and gastro-intestinal catarrh. 

Symptoms. The disease is often not suspected until it is well 
developed. The chief symptoms of vesicular emphysema are diffi- 
culty of 'breathing '(dyspnoea), greatly aggravated on exertion ; more or 
less cough, the result of an attending bronchitis, and the various 
symptoms resulting from dilatation of the heart, particularly cyanosis 
without marked distress. The discomfort of the patient is often in- 
creased by paroxysms of asthma. 

Inspection. The shoulders are rounded, the intercostal spaces 
widened, the vertical diameter elongated, with circumscribed promi- 
nences between the clavicles and nipples, often increased by the 
act of coughing — the peculiar " barrel-shaped " chest, characteristic 
of this disease. 

The character of the respiratory movements is marked, there being 
but slight movement observed on forcible respiration, the chest hav- 
ing the constant appearance of a full inspiration. 

Palpation. The vocal fremitus is diminished, and the cardiac 
impulse depressed and nearer to the sternum. 

Percussion. The resonance is increased (hyper-resonant) over 
all the emphysematous portions, and, if the whole lung be involved, 
extends to the seventh or eighth rib anteriorly and to the twelfth rib 



312 PRACTICE OF MEDICINE. 

posteriorly. The hepatic dullness may not begin until the inferior 
margin of the ribs is reached ; the cardiac dullness is lessened, on 
account of the emphysematous lung nearly covering the heart. 

Auscultation. The vesicular murmur is weakened, and in pro- 
nounced cases almost absent. If bronchitis be present, the inspira- 
tory sound may be rough or sibilant in character, but its duration is 
always shortened. Expiration is always prolonged, and if bronchitis 
be present, may be associated with more or less pronounced moist or 
bubbling rales. 

The first sound of the heart is lessened in intensity and duration, 
the second sound being sharply accentuated. 

Diagnosis. Bronchitis is distinguished from emphysema by the 
absence of dyspnoea, hyper-resonance of the chest, changes in its 
shape, size, and movements, and the disturbance of the circulation. 

Spasmodic asthma, by the paroxysmal character of the affection, 
emphysema being a permanent malady, with attacks of asthma. 

Cardiac diseases due to other causes than emphysema do not have 
the characteristic physical signs of that affection. 

Prognosis. Vesicular emphysema is essentially a chronic disease. 
In itself it rarely proves fatal, but if aggravated from any cause, or if 
associated with frequent or prolonged asthmatic paroxysms, the car- 
diac changes are hastened, general dropsy supervenes, death occur- 
ring from exhaustion, or, more commonly, as the result of intercurrent 
attacks of pneumonia. 

Treatment. It being impossible to restore the altered lung struc- 
ture, the indications for treatment are to relieve the symptoms and to 
endeavor to prevent its further progress. 

For the relief of the asthmatic paroxysms, morphines sulphas com- 
bined with atropines sulphas may be used hypodermically, or ext. 
quebracho fid., f^ss-j (2-4 Cc.) every hour until relief; caffeines 
citrata, gr. ij-v (0.13-0.3 Gm.), repeated, or a combination of nitro- 
glycermian, strychnines sulphas, and morphines sulphas, or large doses 
of potassium iodidum, frequently repeated, or inhalations of oxygen. 

For attacks of bronchial catarrh use : 

1& . Ammonii chloridi, 3 ij 8. Gm. 

Tinct. hyoscyami, ^5' v *5' Cc. 

Glycerini, f^j 30. Cc. 

Syr. prun. virg., ad fijiv ad 120. Cc. 

Sig. — Ilalf-tablespoonful every few hours, well diluted. 



DISEASES OF THE BRONCHIAL TUBES. 313 

To prevent the progress of the affection t remove the bronchial 
catarrh, relieve the difficulty of breathing, and strengthen the cardiac 
action, no one combination seems comparable with the following: 

R. Potassii iodidi, gr. v .3 Gm. 

Strychninae sulph. , gr. -g 1 ^ .002 Gm. 

Liq. potassii arsenit., .... TT\v .3 Cc. 

Aq. lauro-cerasi, f^j 4. Cc. 

SlG. — Four times a day, well diluted. 

But of all means hitherto proposed for the relief of emphysema, 
nothing has approached the inhalation of compressed air, by means 
of the apparatus of Waldenberg. 

For attacks of cyanosis a free venesection often saves life, combined 
with and followed by full doses of spiritus glonoini. 

The dropsy arising from failure of the heart to compensate for the 
circulatory derangement in the lungs may be relieved for a time by 
the use of digitalis and strychnines sulphas, or caffeines citrata, the last 
two being cardiac and respiratory tonics and stimulants, and the last 
mentioned also a diuretic. 



HAEMOPTYSIS. 

Synonyms. Bronchial hemorrhage ; broncho-pulmonary hemor- 
rhage; bronchorrhagia. 

Definition. The expectoration of pure or unmixed blood, usually 
of a bright red color, following the act of coughing. 

Causes. In the majority of cases, the result of tubercular deposi- 
tion in the walls of the minute bronchial arteries ; excessive cardiac 
action ; bronchial congestion ; excessive bodily exertion, straining, 
lifting, or running ; a symptom of hcemophilia (" bleeder's disease "). 

Pathological Anatomy. Haemoptysis rarely causes death in 
itself, so that few opportunities for observing post-mortem appear- 
ances are obtained, and when they do occur, the location of the 
hemorrhage is seldom found. 

The air passages are more or less filled with clotted blood ; the 

mucous membrane is swollen, and of a dark-red color; rarely, pale 

and bloodless. The air cells contain blood clots, or are distended 

with air, the bronchi being filled with clots, preventing its escape. 

27 



314 PRACTICE OF MEDICINE. 

Unless the clots are rapidly removed by expectoration or absorption, 
a secondary inflammation develops around about them. 

Symptoms. "Spitting of blood" occurs suddenly; rarely, it is 
preceded by epistaxis, cardiac palpitation, and some difficulty of 
breathing. 

It begins with a sensation of warmth under the sternum, tickling 
in the throat, a sweetish taste in the mouth, an attempt to remove 
which by the act of coughing is followed by a warm, saltish, bright 
red, frothy liquid gushing from the mouth and nose. The quantity 
of blood raised varies from an ounce to a pint. The appearance of 
the blood depresses the individual, he becoming pale, tremulous, 
often fainting. 

The attack may subside within half an hour to several hours, re- 
turning for several days, in the meantime the expectoration being 
either bloody or streaked with blood. 

A slight febrile reaction, with chest pains, supervenes upon the 
hemorrhage, the result of the inflammation at the site of the bleeding, 
which soon subsides, except where blood clots develop a secondary 
pneumonia, which may undergo the cheesy metamorphosis. 

Auscultation. Coarse, bubbling rales are heard in circumscribed 
portions of the chest. 

Diagnosis. From epistaxis, or hemorrhage from the posterior 
nares, it is distinguished by the absence of air bubbles and an inspec- 
tion of the fauces and the nasal cavities. 

Hazmatemesis, or hemorrhage from the stomach, differs from 
haemoptysis in the blood being vomited instead of expectorated, of a 
dark color, clotted, mixed with the acid contents of the stomach, fol- 
lowed with black, tar-like stools, and the absence of rales in the 
chest. 

Exceptions to the above occur when the blood from the lungs is 
first swallowed and afterward raised by vomiting, or when the hemor- 
rhage in the stomach is caused by the erosion of a large artery, the 
result of ulcer of the stomach ; in these cases, however, the raising of 
blood is preceded by epigastric pain and the blood is not frothy. 

Prognosis. Haemoptysis in itself rarely terminates fatally, al- 
though causing much depression ; the patient rapidly recovers, unless 
secondary pneumonia results. In nine cases out of ten it is the diag- 
nostic sign of phthisis. 

Treatment. Perfect rest in bed, the head and shoulder elevated, 



DISEASES OF THE BRONCHIAL TUBES. 315 

and perfect quiet, the diet to be bland, the drinks cool, the patient 
slowly swallowing small particles of ice. An ice bag over the chest, 
if it does not cause chilliness, is sometimes valuable. Common salt, 
slowly dissolved in the mouth, is a popular remedy, and, if of no real 
benefit, serves to occupy the attention of the patient and friends until 
medical advice is obtained. 

The hypodermic injection of atrophies sulphas, gr. -^ (o.ooi Gm.), 
will usually at once control a hemorrhage. It may be repeated pro 
re nata. The one per cent, solution of nitro-glycerinum (spiritus 
glonoini), in half to minim doses every half hour till relief, often 
promptly stops a hemorrhage. 

The hypodermic injection of ergothi, gr. x-xxx (0.6-2 Gm.), or 
the internal administration of extractum ergota* Jluidum, o^ss-j (2-4 
Cc), are recommended, but I consider them injurious. 

R. Acidi gallici, . . . gr. xv 1. Gm. 

Acidi sulphurici dil., TTlx .6 Cc. 

Aquse cinnamomi, f ^ iv 15. Cc. 

Sic — Repeated every fifteen or twenty minutes. 

Or tinctura matico, foj (4 Cc), or extraction hamamelisjld., rrixx-fgj 
(1.3-4 Cc), alumen, gr. xx (1.3 Gm.), acidum gallicum, gr. v-x 
(0.3-0.6 Gm.), or oleum terebinthina?, Ttlv-xv (0.3-1 Cc), frequently 
repeated. 

If the hemorrhage causes great nervous excitement or depression, 
jnorphina, either hypodermically or internally, to quiet the patient, is 
indicated. 

Inhalatiojis, by means of the steam atomizer, of either MonseT s 
solutio?i or tinctura ferri chloridum, are recommended when the 
above means fail. 

Prof. Da Costa recommends, for frequent small hemorrhages, con- 
tinuing day after day, cupri sulphas [gr. y 1 ^ (0.005 Gm.)], ext. opii [gr. 
^2 (0.005 Gm.)], p. r. n. 



316 PRACTICE OF MEDICINE. 



DISEASES OF THE LUNGS. 



CONGESTION OF THE LUNGS. 

Synonyms. Pulmonary engorgement ; hypostatic congestion. 

Definition. An increase in, or abnormal fullness of, the capil- 
laries of the air cells ; active congestion when the result of an accel- 
erated circulation ; passive congestion when caused by an impeded 
outflow from the capillaries. 

Causes. Active. Increased cardiac action ; over-exertion ; alco- 
holic excesses ; mental excitement ; inhalation of cold or hot air. 

Passive. Obstruction to the return circulation. Dilated heart; val- 
vular diseases ; low fevers (hypostatic congestion); Bright's disease. 

Pathology. The congested or engorged lung has a bloated, 
dark-red appearance ; its vessels are distended to the uttermost, the 
tissues succulent and relaxed, blood flowing freely over the cut surface ; 
a bloody, frothy liquid is present in the bronchi, and the alveolar 
walls are so much swollen that the condensed lung shows scarcely 
any indication of its cellular structure, resembling the tissue of the 
spleen (sple?iification). 

Symptoms. Active. Rapidly developing thoracic distress and 
difficulty of breathing, flushed face / strong, full pulse; throbbi7ig caro- 
tids, cardiac palpitation, and congested eyes, with a short, dry cough, 
followed by scanty, frothy expectoration, slightly streaked with blood. 

Passive. Developed slowly, with difficulty of breathing, blueness 
of the surface, almost continuous hacking cough, followed by scanty, 
blood-streaked expectoration. 

Percussion. The resonance of the lungs slightly diminished, the 
quality of the sound being somewhat tympanitic. 

Auscultation. The vesicular murmur is diminished and accom- 
panied by sub- crepitant rales. 

Duration. Active. Usually from three to five days, terminating 
either by resolution, hemorrhage, or, rarely, pneumonia. The onset 
may be so severe and overwhelming that death rapidly supervenes. 

Passive. Developed slowly, and subject to great variations, de- 
pending upon the cause. 






DISEASES OF THE LUNGS. 317 

Diagnosis. Active congestion of the lungs cannot be distin- 
guished from the stage of engorgement of a true pneumonia. 

Prognosis. An acute congestion of the lungs may prove fatal 
within a few hours, but under prompt treatment it generally terminates 
favorably. 

The passive form is controlled entirely by the cause. 

Treatment. Active. In the strong and vigorous wet cups to the 
chest, or, if the symptoms are pronounced, a general venesection, and 
ice bags over chest and heart. Internally, tinctura aconiti, tf\j-ij 
(0.06-0.12 Cc), every half hour or hour, as indicated, with free 
catharsis with saline purgatives. 

Passive. Dry or wet cups over the chest, hydragogue cathartics, 
and the internal administration of digitalis and strychnines sulphas ; 
if much depression of the vital powers, stimulants, such as spiritus 
frumenti and spiritus ammonia aromaticus, are indicated. 



(EDEMA OF THE LUNGS. 

Synonym. Pulmonary oedema. 

Definition. An exudation of serum into the pulmonary interstitial 
tissue and the alveoli of the lungs ; characterized by dyspnoea, cough, 
and a frothy, blood-streaked expectoration. 

Causes. Pulmonary oedema is the result of stasis, occurring when 
the outflow of venous blood in the lung meets an obstacle that cannot 
be overcome by the right ventricle, as in cardiac diseases, in which 
the left ventricle fails. Bright's disease ; alcoholic excesses, causing 
cardiac depression. Sequela? to other lung inflammations. 

Pathological Anatomy. The lung tissue is swollen, and does 
not collapse when the chest is open. The elasticity of the tissue has 
disappeared, and it pits upon pressure. 

If following acute congestion of the lungs, the color is red ; if a 
symptom of a general dropsy, its color is pale. 

On cutting into the ©edematous spots, an enormous quantity of 
albuminous fluid, sometimes clear, at other times of a red color, mixed 
more or less with blood, flows over the cut surface. The liquid is filled 
with bubbles, is frothy, from being copiously mixed with air, provid- 
ing the air cells have not been entirely filled with serum, thereby 
excluding the air. 



318 PRACTICE OF MEDICINE. 

Symptoms. The pre-eminent symptom is dyspnoea, the breath- 
ing being hurried, labored, and rattling, all the accessory muscles of 
respiration being called into action. The sense of oppression and 
anxiety is extreme. There is also a constant, harassing, short cough, 
and the expectoration is a blood-streaked, frothy mucus. The action 
of the heart may be tremulous or feeble. The face is at first flushed, 
but as the left ventricle fails, or if the effusion into the air cells be 
sufficient to prevent the entrance of air, symptoms of cyanosis rapidly 
supervene, the /#/j^ becoming/^/*?, the surface cold, the breathing 
shallow and hurried, the cough suppressed, stupor replacing the rest- 
lessness, soon deepening into coma. 

Percussion. If no other lung disease, the percussion note is but 
slightly, if at all, impaired. 

Auscultation. The vesicular murmur is lost by the diffused sub- 
crepita7it and bubbling i-ales. 

Diagnosis. Acute pneiononia in the earlier stages is the only 
condition likely to be confounded with oedema of the lungs, but as 
the two diseases progress, the picture of pulmonary oedema is so 
characteristic that it cannot be mistaken. 

Prognosis. Grave, and particularly if occurring in pneumonia, 
cardiac, or Bright's disease. In the majority of instances it is a 
terminal symptom coming on in all forms of acute and chronic 
diseases. 

Treatment. As a rule, remedies are useless. The indication is 
to hold up the left heart, and this is best done by hypodermic injec- 
tions of atropines sulphas, gr. ■£$ (o.ooi Gm.), repeated, which often 
has an almost magical effect ; or strychnines sulphas, gr. ^V (0.0035 
Gm.), repeated every half hour; caffeines citrata, gr. iij-v (0.2- 
0.3 Gm.), sparteines sulphas, gr. j-ij (0.065-0.13 Gm.), every hour or 
two ; or digitalinum, gr. -fa—fa (0.001-0.002 Gm.), repeated every hour 
or two. One or more of these drugs may be advantageously com- 
bined. Occasionally relief follows a free venesection or the appli- 
cation of wet cups. Alcoholic stimulants are often invaluable, as is 
spiritus ammonia aromaticus, frequently repeated. 

The above means may be aided by counter-irritation to the chest, 
or ice-poultices, hot mustard foot-baths, active saline purgatives, diu- 
retics, and inhalations of oxygen. 






DISEASES OF THE LUNGS. 319 



CROUPOUS PNEUMONIA. 



Synonyms. Lobar pneumonia ; pneumonitis ; fibrinous pneu- 
monia ; pleuro-pneumonia ; lung fever; winter fever. 

Definition. An acute, infectious, croupous inflammation, involv- 
ing the vesicular structure of the lungs rendering the alveoli imper- 
vious to air ; characterized by a severe chill, headache, fever, thoracic 
pain, dyspnoea, cough, rusty sputum, and great prostration. 

Causes. Croupous pneumonia is an infective disease caused by 
the diplococcus pneumonia of Fraenkel, " which has its seat of elec- 
tion in, and produces its chief effects on, the lung." The micro- 
organism is found in the sputum and in the lungs in the majority of 
cases. "Occasionally other micro-organisms seem to occasion typi- 
cal fibrinous pneumonia. Among these are the pneumococcus of 
Friedlander, streptococci, staphylococci, the bacillus of typhoid 
fever, the bacillus of influenza, and the bacillus coli communis. In 
some cases in which bacteria other than the diplococcus are supposed 
to be the cause there is doubtless mixed infection, but it must be 
accepted at the present time that a number of micro-organisms are 
capable of causing the disease." (Stengel.) 

All ages liable. Males more frequently affected than females. One 
attack predisposes to another. Debilitating causes render individuals 
more susceptible. Alcoholism is among the most frequent predispos- 
ing factors. It is most frequent in winter, at times occurring epidemi- 
cally, the result of atmospheric conditions ; exposure to draughts and 
cold. Gout, rheumatism, diabetes, and Bright's disease. 

Pathological Anatomy. The most frequent seat of croupous 
pneumonia is the lower right lobe ; the next most frequent seat is the 
lower left lobe ; the next, the upper right lobe, although in children 
and the aged this lobe is affected equally as often as the right lower 
lobe. 

The changes are: I. Hyperemia (engorgement); II. Exudaiio?i 
(red hepatization); III. Resolution (gray hepatization); or it may 
undergo purulent transformation or the development of abscesses 
(yellow hepatization). 

I. Stage of hyper cemia : Congestion, or engorgement, consists in the 
vessels of the alveoli being distended, encroaching upon the cavity 
of the air vesicle ; the lung has a reddish-brown color, is heavier, 



320 PRACTICE OF MEDICINE. 

sinking somewhat lower in water than a normal lung, and having a 
slight exudation upon the vesicular surface. The same changes are 
seen in the adjacent bronchioles. 

II. Stage of exudation : Consists in the exudation of a viscid, fibrin- 
ous fluid, mixed with white and red corpuscles and blood, which 
rapidly coagulate, firmly enclosing the corpuscles and completely 
filling the alveoli. When the exudation and coagulation are com- 
pleted, the lung is red, sinks at once when placed in water, and its 
elasticity is destroyed. When cut into, the color, density, and granu- 
lar appearance so closely resemble the cut surface of a section of the 
liver that Laennec termed the conditoin red hepatization. ' 

A thin section shows under the microscope, as a rule, the lancet- 
shaped diplococcus of Fraenkel, as well as staphylococci and strepto- 
cocci. 

III. Resolutionox gray hepatization follows in the majority of cases, 
the coagulated albuminous exudation undergoing liquefaction and 
absorption, the cellular element undergoing a fatty degeneration, the 
greater part absorbed, the remainder expelled during acts of expec- 
toration, the alveoli returning to their normal condition, both as to 
capacity, function, and elasticity. 

If resolution be retarded and portions of the coagulated exudation 
undergo purulent transformation, changing from a yellowish to a 
greenish-yellow color (yellow hepatization), pus cells are rapidly 
formed, the part becoming a granular, fatty mass. The portions of 
the lung not undergoing this purulent transformation retain the red- 
dish color with intermixed yellowish patches. The purulent con- 
tents may be ejected in part, the remainder undergoing fatty degen- 
eration and finally absorption. 

Abscess of the lung may result from the lung structure becoming 
involved in the purulent disintegration. Abscesses may be solitary 
or in great numbers, which by disintegration of intervening structure 
form one or more large abscesses; these abscesses either terminate 
fatally or open into the pleural cavity, causing empyerna and exhaus- 
tion, or open into the bronchi and are expectorated, or an interstitial 
pneumonia is developed and the abscess encapsulated in a firm cica- 
tricial tissue. 

Gangrene of the lungs may result from blocking up of the bron- 
chial or pulmonary arteries by coagula during any stage of the dis- 
ease. 






DISEASES OF THE LUNGS. 321 

The uninflamed portions of the lungs are hyperaemic and their 
functional activity is increased. 

Death sometimes results from a general oedema of the unaffected 
lung, such cases being often erroneously termed " double pneumonia." 

If inflammation of the pleura be associated with a pneumonia, the 
so-called pleuro-pnetwionia, the changes in the pulmonary pleura are 
characteristic. " An uneven, thin, downy-looking layer of plastic 
exudation covers its surface. This plastic layer may conceal the 
liver-brown color of the pneumonic lung. As the third stage is 
reached, the opposing surfaces of the pleura may become agglutinated. 
The pleuritic changes follow very closely those which occur within 
the lung. The cells in the pleuritic exudation are mainly pus. The 
pleuritic membrane is opaque, congested, and ecchymotic. It may 
become so thick as to give a dull note on percussion, after resolution 
is reached." 

Duration of Stages : stage of congestion, from one to three days ; 
stage of exudation, from three to seven days ; stage of resolution, 
from one to three weeks. 

In severe cases or in the very young, the aged, or the depressed, 
the stage of red hepatization may be fully developed within forty-eight 
hours. 

Endocarditis, either simple or malignant, is a common association. 
Pericarditis is frequent. The spleen is usually enlarged and soft. 

Symptoms. Begins with a severe and usually protracted chill 
(in children often convulsions, adults vomiting), followed by a rapid 
rise of temperature, io3°-io4° F. ; a strong, full, but rapid pulse, soon 
showing evidence of embarrassed cardiac action from obstructed 
pulmonary circulation, either a dull or sharp pain near the nipple, 
aggravated by pressure, breathing, or coughing; shortness of breath, 
the inspiration short and superficial, the expiration accompanied by 
a moan or grunt, the number of respirations increasing to 40, 50, or 
more a minute, causing interrupted speech ; the ratio between pulse 
and respiration maybe 1 to 2 or more ; cough, first short, ringing, and 
harsh, followed by a scanty, frothy mucus, soon becoming semi- 
transparent, viscid, and tenacious, about the second day changing to 
the familiar rusty sputum, becoming more copious and of a yellow 
color as the disease advances ; rarely cases occur with bloody or 
blood-streaked sputum during the continuance of the fever. There 
are present headache, sleeplessness, rarely delirium (early delirium is 
28 



322 PRACTICE OF MEDICINE. 

a grave sign), save in drunkards; epistaxis, flushed countenance, and 
especially over the malar bones is a well-defined mahogany blush; 
gastric disturbances and scanty, high-colored urine, with diminished 
chlorides, and often albuminuria. 

From the very onset of the disease the prostration is of the most 
pronounced character. 

The symptoms continue more or less marked until either the 
fifth, seventh, ninth, or eleventh day, when a crisis occurs, and within 
twenty-four hours convalescence is established, recovery rapidly fol- 
lowing. 

Typhoid pneumonia is a term applied to those cases which are 
accompanied by signs of extreme prostration, delirium, tremor, very 
high temperature, and profuse &nd prolonged exudation. They may 
also terminate by a crisis. 

Bilious pneumonia occurs in cases accompanied by congestion of 
the liver ox bile ducts; the result of venous stasis from pulmonary 
obstruction or from an accompanying acute catarrhal jaundice. In 
malarial districts pneumonia and malaria are often associated, when 
jaundice more or less pronounced occurs. Such cases are termed 
malarial or intermittent pneumonia. 

Alcoholic, or pneumonia of the intemperate, has one very charac- 
teristic symptoin, to wit: early delirium. In pneumonia generally 
the mind is clear, even when all the conditions are unfavorable. 
Pneumonia of the intemperate may begin with symptoms closely 
resembling an attack of delirium tremens, cough, expectoration, and 
pain being very slight, or even absent. 

If purule?it infiltration follow the stage of red hepatization, instead 
of the crisis, symptoms of exhaustion occur, with profuse purulent ex- 
pectoration, high temperature, severe sweats, the tongue brown and 
dry, sordes collecting on the teeth, low delirium, feeble pulse, rapid, 
rattling breathing, the recovery slow, and convalescence tedious. 

Pneumonia in the aged or the insane may be la'tent, coming on 
without chill or pain and with only a slight fever ; the cough and ex- 
pectoration are slight, physical signs ill-defined and changeable, and 
the constitutional symptoms out of all proportion to the amount of 
lung involved. 

Apyretic p7ieumonia are attacks minus fever, the result of exhaus- 
tion and the depressing effect of the infecting agent on the nervous 
system. 






DISEASES OF THE LUNGS. 323 

Aspiration pneumonia is due to the aspiration of fluids of any kind, 
the disease being really of mechanical origin. 

Traumatic pneumonia is the variety resulting from severe contu- 
sions of the chest, the trauma predisposing to the disease by mechan- 
ical injury of the lung, the diplococcus finding suitable nidus at the 
site of injury. 

Inspection. First stage, deficient movement of the affected side, 
due to pain. 

Second stage, the healthy side rises normally, the affected side lag- 
ging behind. If both lower lobes are impervious to air, the diaphragm 
cannot descend and the epigastrium does not project during inspira- 
tion, the breathing being conducted by the upper part of the chest 
(superior costal respiration). 

Palpation. First stage, the vocal fremitus more distinct than 
normal. 

Second stage, the vocal fremitus is markedly exaggerated except in 
those rare instances of occlusion of the bronchi by secretion. 

The cardiac impulse is felt in the normal position. 

Percussion. First stage, the percussion note is slightly impaired, 
indeed, at times having a hollow or tympanitic quality. 

Second stage, dullness over the affected parts, with an increased 
sense of resistance. 

Auscultation. First stage, over affected part, feeble vesicular 
mitrmur, associated with the true vesicular or crepitant (crackling) 
rale, most distinct during inspiration. 

Second stage, harsh, high-pitched, bronchial respiration, at times 
resembling a to-and-fro metallic sound, except in those rare instances 
in which the bronchi are more or less filled with secretion. 

Bronchophony, or distinctly transmitted voice, at times pectoriloquy, 
or distinct transmission of articulated sounds, is present. 

Third stage, breathing changing from bronchial to vesiculobron- 
chial, the crepitant (crepitatio redux) rale returning, and if resolution 
proceed, the breath sounds are associated with large and small moist 
and bubbling rales. 

" The morbid phenomena, physical signs, and symptoms of the 
malady correspond usually in this matter." (Da Costa.) 



324 PRACTICE OF MEDICINE. 

I. Stage of engorgement Crepitant rale ; slight per- Cough ; beginning dyspnoea 
and beginning exu- cussion dullness. and rapidly developed 

dation. >. fever heat. 

II. Stage of solidification Percussion dullness ; bron- Rusty-colored sputum; 
of lung tissue (red chial respiration ; bron- dyspnoea ; cough ; high 
hepatization). chophony. fever with marked even- 

ing exacerbations and 
morning remissions. 

III. Stage of softening The same physical signs as Chills; prostration, etc.; 

(gray hepatization). in the second stage, un- purulent or brownish 

less large abscesses have sputum ; generally high 

formed. temperature. 

Terminations. Asthenic cases recover within two weeks. When 
purulent infiltration supervenes, the disease pursues a tedious course 
of several weeks' duration, with a low exhaustive fever. 

If death occur during the first or second stages, it is usually the 
result of ^.collateral oedema of the uninflamed lung, or cardiac, failure 
and inipaired nerve force. 

If abscesses occur, there are exhausting sweats, frequent cough, 
with a large amount of yellowish-gray, at times blood-streaked, 
expectoration. 

Gangrene of the lungs is a rare termination ; it is associated with 
symptoms of collapse, the expectoration of a blackish, foetid charac- 
ter, with the physical signs of a pulmonary cavity. 

Diagnosis. (Edema of the lungs may be confounded with the 
first stage of pneumonia, but the subsequent history, its presence on 
both sides, and the waterish expectoration and absence of chill and 
pain and the physical signs of pneumonia soon determine the 
diagnosis. 

Pleurisy is oftener confounded with pneumonia than any other dis- 
ease, the points of distinction between which will be pointed out when 
discussing that affection. 

Complications. Acute pleuritis is a frequent complication of 
croupous pneumonia, occurring as often as from ten to twenty-five 
per cent, of cases. The more acute localized pain, the greater em- 
barrassment of respiration, and the usual physical signs of effusion 
are the evidences of a pleuro pneumonia. 

Endocarditis is a common complication, showing irregular but 
protracted temperature record, with chills and sweats and great 
embarrassment of the respiration. 



DISEASES OF THE LUNGS. 325 

Capillary bronchitis is a rare but dangerous complication. Peri- 
carditis, rheumatism, and gout are rare complications. 

Prognosis. Depends upon the extent of the inflammation, the 
dangerous features of croupous pneumonia being cardiac failure, the 
result of an endo- or myocarditis or of embarrassed respiratory circu- 
lation, and the rapid tissue waste, associated with extreme fever (105 ), 
resulting in impaired nerve force. Double pneumonia has a very 
grave prognosis, but it is not nearly so frequent as was at one time 
supposed. The coexistence of pleuritis adds to the gravity of the 
prognosis, although not so fatal as generally supposed. Pneumonia 
of drunkards almost invariably terminates fatally. Typhoid pneu- 
monia, pneumonia of the aged and in the insane, and the so-called 
bilious pneumonia, purulent infiltration, abscesses of the lungs, and 
gangrene, all give a grave prognosis. 

Treatment. If pneumonia be regarded as a constitutional malady 
with a local lesion, then the consolidated lung no more calls for treat- 
ment than does the intestinal ulcer of typhoid fever, but the general 
condition of the patient is to govern in the management and not the 
local changes in the thorax. A simple pneumonia attacking persons 
previously in good health requires no more active treatment than any 
of the so-called self-limited diseases, provided only that the extent of 
the disease be moderate, and there be no complication. 

The much-discussed question of venesection is now a settled prob- 
lem in the affection ; if we bleed, it is " not because of pneumonia, but 
in spite of pneumonia" Called to a case in the first stage or early in 
the second stage, who has been vigorous and otherwise healthy, with 
a high temperature, 105 or more, with frequent pulse, one hundred 
and twenty beats or more, or a slow, full pulse showing cardiac 
oppression, flushed surface, and marked dyspnoea, a copious bleed- 
ing is indicated, and the same may be said when symptoms of collat- 
eral oedema threaten; this is bleeding for symptoms and not for the 
disease per se. 

There is no remedy which can exert a favorable influence upon the 
pneumonic process. Many cases recover without, and many cases in 
spite of, treatment. When treatment is instituted, be guided by the 
fact that you are not to treat pneumonia, but a patient with a pneu- 
monia. 

At the onset, if venesection is not indicated, relief of the pain may 



326 PRACTICE OF MEDICINE. 

follow the use of dry or wet cups. If the tongue be coated and the 
gastro-intestinal canal deranged, a calomel purge is indicated. 

R. Hydrargyri chloridi mitis, . . . gr. ij .13 Gm. 

Sodii bicarb. , gr. iv .26 Gm. 

Pulv. ipecac, gr. j .065 Gm. M. 

Ft. chart. No. iv. 

Sig. — One every two hours, followed in two hours after last powder by 
mild saline. 

Action on the skin and kidneys by refrigerant mixtures or small 
doses of Dover's powder is valuable. The administration of the 
arterial sedatives, aconitum and veratrum viride, are recommended 
by Drs. Da Costa arid H. C. Wood. In pneumonia of children the 
use of small, frequently repeated doses of tinctura aconiti in the early 
stage is most useful. 

Poultices are of slight value, but the use of home-made mustard 
plasters, weakened with flour, is useful in all stages. If the heart be 
weak from the onset, either of the following are valuable : digitalis, 
caffeines citraia, nitro-glycerinum , spartei?i t or strycJi7iina. Indeed, 
it seems a good practice to administer strychnina in full doses from 
the onset. Quinines sulphas, gr. ij-v (0.13-0.3 Gm.) every three or 
four hours, is always valuable. 

Second Stage. It is at this period of a severe attack of acute pneu- 
monia that two prominent indications for treatment arise — heart 
insuffcie?icy and high temperature. 

To sustain the heart is one of the most important indications, for 
experience shows that cardiac failure is responsible for a large num- 
ber of deaths in this affection. Strych?iince sulphas, gr. 3V-2V (° °° 2 - 
0.003 Gm.), repeated every few hours by mouth or by the hypodermic 
method, or caffeines citrata, gr. ij-v (0.13-0.3 Gm.) every four hours, 
or tinctura strophanthus, n\,v-x (0.3-0.6 Cc.) every three hours, are 
valuable cardiac tonics in pneumonia. The availability of digitalis 
and nitro-glycerinum depends upon a careful study of the pulse. If 
the tension is low, the result of relaxation of peripheral blood vessels, 
— vaso-motor paralysis, — digitalis in full doses is indicated ; but if the 
tension is high, with embarrassed right heart, nitro-glycerinum every 
hour or two, with spiritus ammonii aromaticus , is the indication. 
Alcoholic stimulants judiciously employed are most efficient means 
for preventing or overcoming the cardiac failure. The amount can 



DISEASES OF THE LUNGS. 327 

only be determined by a careful study of each case, as a few ounces 
in the twenty four hours may answer in one, while another may 
require eight or ten ounces. It is well to begin with small doses, 
increasing or decreasing as its effects are good or bad. The indi- 
cator of the heart 's condition is the pulse. In the aged, the feeble, or 
in those accustomed to the use of alcohol, stimulation is indicated 
from the onset. Other indications would be a frequent, feeble, 
irregular, or intermitting pulse ; a dicrotic pulse ; delirium, muscular 
tremor, and subsultus ; immediately following crisis, and the period 
of collapse. 

To reduce the temperature is at times an important indication. If 
the fever is under 103 F., cool sponging with alcohol and water, or 
water alone, is sufficient. If the temperature is above 104 F., anti- 
febrin, gr. v (0.3 Gm.), may be used every three hours until a reduc- 
tion occurs. Strychnines sulphas, or caffeines citrata, may be added 
to each dose. Phenacetin or acetanilidum are also valuable, and 
considered less depressing, but it is to be remembered that a temper- 
ature under 104 is as normal to pneumonia as the dyspnoea or the 
rusty sputum, and so use antipyretic drugs with caution. 

The use of the cold pack or of cold baths for reducing the temper- 
ature in acute pneumonia has not given the success expected. 

Dr. Mays strongly advocates the use of ice bags to the chest in 
pneumonia. He says: "Very often it is found that the application 
of the ice to an affected spot is immediately followed by a marked 
lowering of the temperature and improvement in the physical signs 
in the part." I am able, from an experience of five years, to endorse 
this statement. 

For dyspnoea and pain, a hypodermic injection of m or phince sul- 
phas, repeated p. r. n. The dyspnoea is often relieved by inhalations 
of oxygen, but do not expect too much from oxygen as there is some 
additional factor besides the mechanical one of consolidation of the 
lung producing the dyspnoea, for the consolidation is just as marked 
immediately after the crisis, while the dyspnoea is wonderfully relieved. 

The diet must be of the most nutritious but easily digestible char- 
acter, and given at periods of every three hours, watching that the 
food is assimilated. A distended stomach and abdomen is danger- 
ous. Strong black coffee throughout the disease is valuable. 

Third Stage. The treatment is a continuation of that of the second 
stage, with the addition of the following valuable combination : 



328 PRACTICE OF MEDICINE. 

I J . Ammonii chloridi, gr. v-x -3~.6 Gin. 

Strychnine sulph., gr. Jj .003 Gm. 

Aquae chloroformi, f gj 4. Cc. 

vSyr. prun. virg., f 3 iij 12. Cc. M. 

Sig. — Every three hours, diluted. 

Many cases are favorably influenced by an expectorant from the 
onset of the disease. 

Co?ivalescence. Nutritious diet, quinine sulphas in tonic doses, 
ferritin, together with a good blood-making wine or a good prepara- 
tion of malt. If the consolidation shows a disposition to linger, 
blisters may be used. 

The various symptoms other than those particularly mentioned are 
to be met, as they arise, by their proper remedies. 

For typhoid pneumonia, purulent infiltration, abscess of the lungs, 
or pneumonia in drunkards, the weak, or the aged, quinince sulphas, 
ferrum, nutritious diet and bold stimulation, and the free use of 
ammonii carbonas or spiritus ammonia aromaiicus, caffeines citrata, 
and strychnine sulphas, — these last two being respiratory and car- 
diac tonics, — are the indications. 

Sleeplessness is an annoying symptom frequently requiring treat- 
ment. Balfour, of Edinburgh, advocates chloral. With strychnines 
sulphas it is safe and satisfactory. The same can be said for trional 
with strychni?icz sulphas. 

The so-called antiseptic treatment of acute pneumonia is still under 
trial, and no definite opinion can be expressed concerning it. 



CATARRHAL PNEUMONIA. 

Synonyms. Broncho-pneumonia; lobular pneumonia; capillary 
bronchitis (?). 

Definition. An acute catarrhal inflammation of the bronchioles 
and alveoli of the lungs, characterized by fever, cough, dyspnoea, 
copious expectoration, and great depression. 

Causes. From an extension of a bronchial catarrh downward; 
following the eruptive fevers, especially measles ; complicating whoop- 
ing cough. Persons of the rickety or scrofulous diathesis, in whom 
there is a greater irritability of the epithelial elements, are particularly 
predisposed to this form of pneumonia on slight exposure ; emphy- 



DISEASES OF THE LUNGS. 329 

sema ; diseases of the heart ; most frequently seen in childhood and 
old age. The inspiration of particles of food and mucus in the last 
stages of low diseases — the aspiration or deglutition pneumonia — is 
of the catarrhal variety. 

Bacteriological investigations seem to indicate that broncho-pneu- 
monia is due to more than one germ, although the diplococcus 
pneumoniae is the most frequent etiological factor. 

Pathological Anatomy. Hyperemia of the mucous membrane 
of the bronchi, extending to the connective tissue of the bronchioles 
and accompanying arterioles and to the alveoli, with swelling and 
succulence of these tissues, accompanied by an abnormal sec?~etion and 
an immense production of young cells from the proliferation of the 
bronchial and alveolar epithelium, admixed with a yellowish, creamy, 
mucoid material, which blocks up the bronchioles and air cells. 

The affected parts first have a reddish-gray, soon changing to a 
yellowish-gray, color, due to the rapid metamorphosis of the newly 
developed cells. If the fatty change be completed, absorption takes 
place and the consolidation is removed; if it remain incomplete, the 
cells atrophy, the little mass becoming caseous, and the disease 
passes into a chronic state. 

The bronchial tubes also participate in the disease ; the walls be- 
come thickened, from a hyperplasia of the connective tissue {peri- 
bronchitis}, and their calibre is often dilated. 

Symptoms. Catarrhal pneumonia begins as a catarrhal bron- 
chitis. It may be either acute, subacute, or chronic in its course. 

J* cute variety : Its onset is announced by a gradual rise of tem- 
perature to io2°-io3° F., the febrile phenomena assuming a typical 
remittent character, with rapid, laborious, and shallow breathing, as 
shown by the widely dilated nares and violent action of all the acces- 
sory muscles, while the insufficient distention of the lungs is shown 
by the great recession of the lower part of the chest walls and sinking 
in of the intercostal spaces. The inspiration is short and imperfect, 
the expiration noisy and prolonged; the pulse is frequent, 100-120 
or more, and somewhat compressible ; the cough, which, during the 
bronchitis, was loose, now becomes short, hacking, dry, and painful, 
soon followed by more or less copious muco-purule?it expectoration ; 
the appetite is impaired, bowels somewhat loose, urine scanty, high- 
colored, and the surface frequently covered with a more or less 
profuse perspiration. 



330 PRACTICE OF MEDICINE. 

The subacute and chronic varieties have the same general symp- 
toms, but the duration is longer and the exhaustion greater. 

The progress of catarrhal pneumonia is sometimes, although not 
often, a very acute one. The disease may prove fatal in a few days, 
especially if it attack feeble children ; in such the countenance be- 
comes pale and livid, the lips bluish, the eyes dull, and a restlessness 
giving place to apathy, and a continually augmented somnolence. 

Resolution, when it occurs, is by lysis, several weeks elapsing 
before complete recovery. 

Percussion. Dullness, scattered in patches, over both lungs, 
the intervening healthy lung often giving a more or less hollow or 
tympanitic note. 

Auscultation. Vesiculobronchial breathing, changing to moist 
bronchial breathing, associated with small bubbling (sub-crepitant) 
rales. As the disease progresses toward resolution, the rales become 
larger (large bubbling) and more numerous. If pneumonic phthisis 
result, physical signs indicative of that condition are soon evident. 

Sequelae. Attacks of catarrhal pneumonia complicated with 
atelectasis, or collapse of the lobules, when recovery occurs, are fol- 
lowed by emphysema of the lungs. 

If the catarrhal products which fill the alveoli and bronchioles and 
intervening connective tissue do not rapidly undergo complete fatty 
metamorphosis and consequent absorption, pneumonic phthisis re- 
sults. 

Diagnosis. Ordinary bronchial catarrh differs from catarrhal 
pneumonia by the absence of dyspnoea, fever, and dullness on per- 
cussion, and the presence of the large bubbling rales, and also by the 
subsequent history of the two affections. 

Croupous pneumonia is a unilateral disease ; catarrhal pneumonia 
is bilateral and diffused over both lungs — the former a self-limited 
disease, the latter having no fixed duration. 

Acute tuberculosis at its onset is characterized by the presence of a 
capillary bronchitis, a differentiation being possible only by a study 
of the clinical history and course of the two maladies and the presence 
or absence of the tubercular bacilli. 

(Ede7?ia of the lungs is a bilateral disease associated with a short, 
dry cough, and dyspnoea, but lacks the previous catarrhal history and 
high temperature of catarrhal pneumonia. 

Prognosis. Fully one-half of the cases of true catarrhal pneu- 



DISEASES OF THE LUNGS. 331 

monia terminate fatally. The prognosis must be guarded in scrofu- 
lous or rachitic subjects, or those enfeebled by other diseases, for, 
unless prompt resolution can be effected, it will terminate fatally 
early, or develop pneumonic phthisis. Have seen cases continuing 
up and down for eight and ten months, and finally make a good 
recovery. 

Treatment. Confinement to bed is paramount, although the 
position of the patient is to be frequently changed. The diet must 
be of the most nutritious character, administered at frequent intervals : 
milk, eggs, chicken, beef, mutton and oyster broths are the most 
suitable articles. The steady use of brandy or whiskey throughout the 
attack is of importance, regulating the amount by the age of the 
patient and the severity of the attack. 

Locally a weak mustard plaster followed with a cotton-batting 
jacket is valuable. Poultices are of little use. The febrile symptoms 
and early cough are often modified by the following mixture : 

Be. Potassii citratis, gvj 24. Gm. 

Spts. setheris nitrosi, f 5 iv 15. Cc. 

Tinct. opii camphorat. , f 5 iv 15. Cc. 

Liquor, potassii citratis, ... adf^vj ad 180. Cc. M. 

Sic — Dessertspoonful every three hours. 

Early in an attack, in children with high temperature, tinctura aco7iiti, 
in small, frequently repeated doses is valuable. If the fever persists, 
a combination of phenacetin or antifebrin with camphor or digitalis 
is useful. The ice bags or poultices are as strongly urged for broncho- 
pneumonia as for croupous pneumonia, and in sthenic cases should 
be given a trial. 

For the catarrhal process, the air of the apartment should be main- 
tained at an even temperature and moistened by disengaging the 
vapor of water in it. The following combination is of great utility in 
nearly all cases, regulating the dose in accordance with the age of the 
patient : 



R • Ammonii carbonat 
Ammonii iodidi, 
Mucil. acacire, . 
Syr. glycyrrh., . 
Syr. prun. virg., 
SlG. — Every three hours 



• gr. v 
■ S v - v_x 

. q. S. 

ad fg iv ad 



•3 


Gm. 


.3- 


.6 Gm. 


q. s. 




4- 


Cc. 


15. 


Cc. 



ich pleasanter way of administering the ammonia salts is in 



332 PRACTICE OF MEDICINE. 

capsules, each containing about two and one-half grains of each salt 
with an aromatic oil. Terpinum hydras acts remarkably well in 
many lingering cases. The spiritus ammonii aromaticus in either 
chloroform or cherry-laurel water makes an excellent mild, stimu- 
lating expectorant. 

For C07ivalescence, nutritious food, ferri iodidum, quinines sulphas, 
and oleum morrhucE. 

Locally : repeated application of mustard poultices or turpentine 
stupes, followed by cotton j acket. If the inflammatory processes tend 
to become chronic, scattering blisters should be used. 



PULMONARY TUBERCULOSIS. 

Synonyms. Phthisis pulmonalis ; phthisis ; consumption ; pneu- 
monic phthisis ; tubercular phthisis. 

Definition. An infective disease, caused by the bacillus tubercu- 
losis, the lesions of which are characterized by nodular bodies called 
tubercles or diffused infiltrations of tuberculous tissue, which undergo 
caseation or sclerosis, and may finally ulcerate, or, in some situations, 
calcify. (Osier.) 

Clinical Varieties. I. Acute miliary tuberculosis; II. Pneu- 
monic phthisis ; III. Tubercular phthisis ; IV. Fibroid phthisis. 

Cause. It is now generally accepted that all varieties of pulmon- 
ary consumption are due to the active presence of the bacillus tuber- 
culosis, discovered by Koch in 1880. The lung tissue must be in a 
receptive state, as the bacilli may be present in the respiratory tract 
without the development of the disease. 

Any condition that lowers the tone of the general system renders 
the tissues susceptible to the changes produced by the tubercle bacilli. 
These will be enumerated in speaking of the clinical varieties of the 
disease. 



ACUTE MILIARY TUBERCULOSIS. 

Synonyms. Acute phthisis; galloping consumption. 

Definition. An acute infective febrile affection, due to the rapid 
eruption in various parts of the body, but especially in the lungs, of 
miliary tubercles ; characterized by high fever, rapid pulse, hurried 



DISEASES OF THE LUNGS. 333 

respiration, pains in the chest, cough, profuse expectoration, and rapid 
prostration. 

Causes. In the majority of cases it is the result of an auto-infec- 
tion, arising from either an active or latent tuberculous focus. Cases 
develop in which no cause can be assigned. Often follows measles, 
whooping-cough, variola, and influenza. 

Most frequent between puberty and middle life. 

" That the gray granulation is deposited throughout the body under 
the influence of certain conditions of irritation, it is necessary that a 
peculiar vulnerability of the constitution exist — in other words, that it 
be of the scrofulous type." 

Clinical Forms. General or typhoid, pulmonary and cerebral. 
The cerebral will be described in the section on nervous diseases. 

Pathological Anatomy. Pulmonary form. " The gray granu- 
lation or miliary tubercle consists of a fine reticulation of fibres, with 
a mass of epithelioid cells and granules, and often having a giant cell 
for its centre." 

The deposit is generally over both lungs and the bronchial tubes, 
and is followed by hypersemia, increase of secretion, having a viscid 
and adhesive character, and the destruction of all the tissue with which 
it comes in contact. 

Deposits also take place in the brain, pleurae, intestines, peritoneum, 
and kidneys. 

General or Typhoid. — Symptoms. Gradual progressive weak- 
ness, with loss of appetite ; dry, clean tongue ; costive bowels, flushed 
cheeks ; fever, irregular in type, and rapid, feeble pulse. Rarely the 
temperature reaches 103 F., to 104 F., associated with a mild 
delirium. The respirations are increased with slight or no cough, and 
little or no expectoration. Often the symptoms of a diffused bron- 
chial catarrh of the smaller tubes are present. As the symptoms 
continue the prostration increases, cyanosis develops, the patient 
growing stupid, gradually deepening into coma and death. 

Diagnosis. The symptoms of acute phthisis point to an acute 
general infection, and the disease is apt to be mistaken for typhoid 
fever. The points of difference are the absence of the typical typhoid, 
or step-like, temperature record, the characteristic eruption, and the 
diarrhoea. The. differential diagnosis can be more readily determined 
by the Widal test and the diazo-reaction in the urine. 

Prognosis. Recovery is the rarest termination. 



334 PRACTICE OF MEDICINE. 

Treatment. Expectant and symptomatic. 

Pulmonary Form. Symptoms. The onset is usually sudden, 
with a chill or chilliness, followed by fever, io2°-io4° F., rapid, 
dicrotic pulse, 120-140, cough, with scanty, glairy sputum, increased 
respiration, 30-50 per minute, pain in the chest, hot skin, dry tongue, 
deranged digestion, and great prostration, the severity of the symp- 
toms rapidly increasing, with evidences of cyanosis, the sputum 
becoming more abundant and often rusty in color, with more or less 
frequent attacks of hcemoptysis, soon followed by headache, vertigo, 
sleeplessness, often delirium, coma, and death. 

If deposits have occurred in the meninges or the intestines, symp- 
toms of these affections are superadded. 

Percussion. The percussion resonance is normal until consider- 
able deposits have occurred, when it is either slightly impaired or 
even slightly tympa?iitic. With the development of cavities the am- 
phoric percussion note is present. 

Auscultation. Often little change in the vesicular murmur, but 
diffused rales of bronchial catarrh, or vesiculo-bronchial breathing, 
associated with large and small, moist or bubbling rales, soon followed 
by bronchial and brcncho-cavernous breathing, with large and small, 
moist and circumscribed gurgling rales. 

Duration. Acute phthisis usually terminates fatally in from four 
to twelve weeks. Rarely of several months' duration. 

Diagnosis. Commonly mistaken for typhoid fever with lung 
complications, an error that is readily made unless a close study of 
the history, symptoms, physical signs, and sputum be made. The 
Widal test may assist in determining the diagnosis. 

Treatment. There are no means of retarding the progress 
of this malady. Loomis says : " Morphia in small doses — -fa 
of a grain (0.003 Gm.) hypodermically every six or eight hours — has, 
in my hands, been more satisfactory in staying the progress of the 
disease, prolonging life, and keeping the patient comfortable than 
any other plan." 

Dr. McCall Anderson claims that subcutaneous injections of 
atropine sulphas check the exhausting sweats, and that quininas 
sulphas, digitalis, and opium reduce the temperature, and if they fail, 
ice-cloths to the abdomen will accomplish the desired result. 

The various symptoms should be met as they occur, the patient at 
the same time being supplied with large quantities of stimulants, and 
full doses of strychninae sulphas and arsenicum. 



DISEASES OF THE LUNGS. 335 



PNEUMONIC PHTHISIS. 

Synonyms. Chronic catarrhal pneumonia ; catarrhal phthisis ; 
caseous pneumonia ; caseous phthisis. 

Definition. A form of pulmonary consumption characterized by 
the destruction of the pulmonary tissue resulting from the action of the 
bacillus tuberculosis, causing the caseation or cheesy degeneration of 
inflammatory products in the lungs, and the subsequent softening and 
destruction of the caseous matter, with greater or less destruction of 
the pulmonary tissue ; characterized by hectic fever, cough, shortness 
of breath, purulent expectoration, and more or less rapid prostration. 

Causes. The predisposing factor in the etiology of pneumonic 
phthisis is a strumous or scrofulous diathesis, or a condition of lowered 
health, the result of various unfavorable hygienic influences. 

The exciting causes are : the irritation produced by the presence of 
the bacillus tuberculosis and a catarrhal pneumonia in any portion 
of the lung, but especially at the apex ; inflammation occurring about 
a blood clot ; inhalation of irritant particles occurring in such occu- 
pations as weaving, grinding, mining, milling, cigar-making, and 
the like. Many cases of pneumonic phthisis can be traced to an 
attack of influenza a year or so before in individuals having the 
peculiar diathesis. 

Pathological Anatomy. When a pneumonia terminates in 
resolution, the inflammatory products are absorbed by first undergoing 
a fatty metamorphosis. If the fatty metamorphosis be incomplete, the 
cells are atrophied and undergo the caseous degeneration, which con- 
sists in the absorption of the watery parts, the fatty degeneration of 
the cellular elements, and the granular disintegration of the fibrinous 
material, so that ultimately a soft, solid mass is produced, yellowish 
in color, having the appearance of cheese. 

The destructive changes are thus described by Niemeyer: " Cells, 
the products of inflammation, accumulated in the alveoli and minute 
bronchi, crowd upon each other, becoming densely packed, and thus 
by their mutual pressure they bring about their own decay, as well 
as that of the lung textures, by interfering with their nutrition, the 
alveolar walls being also themselves damaged by the inflammatory 
process." 

The position of the catarrhal pneumonia resulting in the above 



336 PRACTICE OF MEDICINE. 

changes is usually at the apex or under the lower inner scapular re- 
gion, but it may occur at any portion of the lungs, or a whole lung 
becomes infiltrated, and undergoes the cheesy degeneration (phthisis 
florida). 

As in croupous pneumonia, so in pneumonic phthisis is there in- 
volvement of the overlying pleura of tubercular character in the 
latter disease. Rarely rupture of lung and pleural structure occur, 
causing tubercular pneumohydrothorax. 

Symptoms. Pneumonic phthisis occurs in three forms — the 
chronic, the subacute, and the acute. 

Chronic form. The origin is rather insidious, the individual being 
susceptible to "colds," or " catarrhs," on the slightest exposure; 
gradually a persistent cough, with the expectoration of muco-pus, is 
established, each severe cold being accompanied with chill, fever, 
pain in the chest, and either slight hemorrhages or blood streaked 
sputa. Finally, the catarrhal symptoms become persistent, with 
morning chills, evening fevers, and rather profuse night-sweats, dis- 
tressing cough, profuse muco-purulent sputa, containing the bacilli, 
great weakness and exhaustion, loss of appetite and feeble digestion, 
the symptoms growing persistently worse, death occurring from 
exhaustion after one or two years' duration. 

Subacute variety. History of an acute attack of pneumonia of one 
or two weeks' duration, followed by a decided improvement, but not 
complete recovery. After a lapse of some weeks or months symp- 
toms of pulmonary softening beg'm , destroying the lung structure and 
forming cavities, accompanied by chills, fever, night-sweats, emaci- 
ation, cough, muco-purulent and blood-streahed expectoration contain- 
ing the bacilli, the patient dying from exhaustion within a year. 

Acute variety, the so-called phthisis florida, runs a rapid course, 
beginning either as a croupous or catarrhal pneumonia, involving 
the whole of one or part of both lungs, associated with rapid loss of 
flesh and strength, high but variable temperature, io3°-io5° F., with 
remissions, profuse night-sweats, shortness of breath, severe cough, 
profuse, purulent, and blood-streaked sputa containing the bacilli, loss 
of appetite, and feeble digestion, the patient succumbing in a few 
weeks or months from exhaustion. 

A decided remission in the local and general symptoms of the acute 
variety may occur, the disease afterward pursuing a more chronic 
course. 



DISEASES OF THE LUNGS. 337 

Inspection. Shows deficient respiratory movements of the dis- 
eased portion of the lungs. 

Palpation. Increased vocal fremitus over the consolidated lung 
tissue and cavities. 

Percussion. The percussion note varies from a slight impair- 
ment of the normal note at either apex to dullness, and when cavities 
are formed, associated with scattered points of the tympanitic or 
hollow note. If the cavities communicate with a bronchial tube, the 
cracked-pot or cracked-metal sound is elicited. If the cavities are 
filled with pus, the percussion note is dull. If the pus be expelled, 
the tympanitic or cracked-pot sound returns. 

Auscultation. The vesicular murmur is unimpaired in those 
parts free from disease; it \§ feeble or indistinct if many bronchioles 
are obstructed; and is harsh or blowingM the bronchioles are nar- 
rowed. The inspiratory sound will be jerking, and the expiratory 
sound prolonged and blowing when the lung has lost its elasticity. 

Associated with the impaired vesicular murmur is Vifine, dry, crack- 
ling sound (crepitation), appearing at the end oj 'inspiration. If bron- 
chitis be associated, large and small moist or bubbling rales are also 
heard during respiration. 

When cavities form, either bronchial or broncho-cavernous respira- 
tion is heard, associated with more or less distinct gurgling rales. If 
the cavity be free from pus and have rather firm walls, the breathing 
is more amphoric in character. 

Diagnosis. Catarrhal bronchitis has many points of resemblance 
to pneumonic phthisis. The subsequent course of the latter, with the 
high temperature, prostration, emaciation, sputa containing bacilli, 
and physical signs will prevent error. 

Acute fibrinous and catarrhal pneumonia, often after a course of 
two or three weeks, show the bacilli and yet are not recognized as 
tuberculosis. It is a safe rule of practice to suspect tuberculosis and 
examine daily for the bacilli in all cases of pneumonia that show the 
least tendency to linger, and particularly where there are chills and 
a remittent temperature record. 

Prognosis. Acute variety, the phthisis florida, usually terminates 
fatally within a few months. 

The subacute and ch?'onic varieties may, under judicious treatment 
and favorable hygienic conditions, be arrested, the caseous matter 
partly expectorated and partly absorbed, leaving more or less loss of 
29 



338 PRACTICE OF MEDICINE. 

structure, cicatricial tissue supplying its place, which after a time 
contracts, causing more or less retraction of the chest walls. 

Cases not properly treated, either from carelessness or poverty, 
succumb after a year or two. 



TUBERCULAR PHTHISIS. 

Synonyms. Tuberculosis; consumption; incipient phthisis; 
chronic phthisis ; chronic ulcerative phthisis. 

Definition. A chronic pulmonary disease caused by the bacillus 
tuberculosis, resulting in the deposition of tubercle in the lung structure, 
which in turn undergoes ulceration and softening which results in a 
septic infection, characterized by progressive failure of health, fever, 
cough, dyspnoea, emaciation, and exhaustion. 

Causes. Hereditary and acquired susceptibility to the influence 
of the bacillus tuberculosis. It is questionable if an individual is born 
with pulmonary tuberculosis, but makes his advent with tissues that 
are a congenial soil for the growth and ravages of this wide-spread 
germ. Amongst the acquired causes are syphilis, alcoholism, chronic 
nephritis, certain occupations, and living in damp, overcrowded, 
dark, and badly ventilated locations. Debility following an attack of 
influenza predisposes to the deposition of tubercle. 

Pathological Anatomy. Tubercle is a grayish-white, translu- 
cent, and semi-solid granulation, about the size of a millet-seed, most 
commonly deposited in the walls of the bronchioles, or around the 
small blood-vessels, — a peri-arteritis, — exciting alow form of inflam- 
mation, the result of its own death. The masses of tubercle soon 
undergo softening (cheesy transformation) ; the lung structure is sec- 
ondarily affected, undergoing softening, which results in more or less 
destruction of the tissue, whence cavities are formed. 

The inflammation may extend to the small arteries, causing hemor- 
rhage. 

The deposit of tubercle is generally at one of the apices, and " once 
present in an apex, the disease usually extends in time to the 
opposite upper lobe ; but not, as a rule, until the lower lobe of the 
lung first affected has been attacked. Lesions of the base may be 
primary, though this is rare." Depositions may also occur in the 
brain, intestines, and liver. 



DISEASES OF THE LUNGS. 339 

The pleura is usually the seat of a chronic inflammation (dry 
pleurisy, tubercular), resulting in the obliteration of the pleural cavity. 

Symptoms. The symptoms correspond closely to the stages of 
deposition, of softening, septic infection, and of the formation of cavi- 
ties. 

The development is insidious , with increasing dyspepsia and ancemia, 
the loss of appetite, distress after meals, and feeling of weakness, 
often misleading the patient and physician for some time until the 
occurrence of an irritable heart, a slight, dry, hacking cough, referred 
to the throat or stomach, scanty, glairy expectoration, gradual loss of 
weight, impaired muscular strength, pallid appearance, and a more 
or less copious hcemoptysis. Pain, sharp in character, below the 
clavicles, is often present. These symptoms are characteristic of the 
development of the disease. 

The beginning of softenifig is announced by increased cough, freer 
expectoration, showing under the microscope the bacilli, dyspnoea in- 
creased on exertion, morning chills, evening fever, night-sweats — the 
so-called hectic fever, diarrhoea, increased emaciation and weakness, 
the patient, however, continuing very hopeful. 

With the formation of the cavities the cough is more aggravated, 
with profuse and purulent expectoration, at times containing yellow 
striae, the amount depending upon the number and size of the cavi- 
ties ; haemoptysis is not common at this stage ; the pulse rapid and 
weak, increased hectic, burning of the soles and palms, copious 
night-sweats, greater debility and emaciation, with oedema of the feet 
and ankles, denoting failure of the circulation, death soon following 
from asthenia, the mind clear and hopeful to the end. 

Inspection. First stage, often shows slight depressions in the 
supra-clavicular, and at times in the infra-clavicular regions. 

Palpation. Second stage, the vocal fremitus is slightly increased 
at both or either apex. 

Percussion. First stage, slight hnpairment of the normal per- 
cussion resonance can sometimes be elicited at both or either apex. 
Second stage, the resonance is impaired, and may be even dull. 
Third stage, dullness with circumscribed spots of the amphoric, or 
tympanitic or cracked-pot sound. 

Auscultation. First stage, inspiration jerky, expiration pro- 
longed, the pitch higher than normal, the inspiration associated with 
crackling rales at both or either apex. 



340 PRACTICE OF MEDICINE. 

Second stage, vesico-bronchial breathing, associated with sub-crepi- 
tant and large and moist or bubbling rales. 

Third stage, broftchial, broncho-cavernous, and cavernous respira- 
tion, associated with large and small moist or bubbling, and localized 
gurgling rales. 

Bronchophony in its various degrees is associated with the second 
and third stages of tuberculosis. 

Complications. Tubercular diseases of the brain, larynx, pleura, 
intestines, and peritoneum ; perineal abscess leading to fistula, endo- 
carditis, and myocarditis. 

Diagnosis. The early diagnosis of tubercular phthisis rests mainly 
on the history, together with the symptoms and physical signs. In 
the first stage it is often mistaken for dyspepsia, anaemia, malarial 
fever, or disease of the heart ; if the bacilli can be found in the sputum, 
the diagnosis is settled. 

Prognosis. In the main unfavorable, although under proper 
treatment, change of climate, and like favorable conditions life may 
be prolonged for years. 



FIBROID PHTHISIS. 

Synonyms. Chronic interstitial pneumonia ; cirrhosis of the 
lungs ; Corrigan's disease. 

Definition. A hyperplasia (thickening) of the pulmonary con- 
nective tissue, resulting in atrophy and degeneration of the vesicular 
structure, associated with bronchial inflammation ; characterized by 
cough, profuse expectoration containing the bacillus tuberculosis, 
fever, emaciation, and ultimately death by asthenia. 

Causes. Hereditary predisposition ; inhalation of irritants and 
associated with certain occupations, such as stone cutting, grinding, 
etc. Following lobar pneumonia ; chronic bronchitis ; alcoholism ; 
syphilis; chronic nephritis. 

Pathological Anatomy. In addition to the pneumonic changes 
in the lung structure, there is developed a reparative or fibrous process 
resulting in thickening of the bronchial mucous membrane and dila- 
tation of the air tubes. Hyperplasia of the pulmonary connective 
tissue, resulting in the compression and consequent destruction of the 
vesicular structure, which is assisted by the contraction of the newly 



DISEASES OF THE LUNGS. 341 

formed tissues. Sooner or later catarrhal pneumonia results, the 
product undergoing the cheesy degeneration, cavities being formed, 
and as a result of the long-continued suppuration, tubercular deposi- 
tions occur, hastening the destruction of the lung tissue. 

Prof. Da Costa has reported a number of cases of "grinders' 
phthisis," in whose sputum was found the "bacillus tuberculosis," 
and in whose family history there were no traces of consumption. 

Symptoms. The course is chronic, beginning as a bronchial 
catarrh, worse in winter, better in summer, when, after several years, 
the cough becomes more continuous, the expectoration freer and 
muco-purulent, containing the bacilli tuberculosis in large numbers. 
Gradually hectic fever develops, with night- sweats, dyspnoea, and 
rapid emaciation, soon followed by oedema of the fee,t and ankles, the 
result of failing circulation, death occurring by asthenia. 

Inspection. Depression of the chest walls. 

Percussion. Impaired resonance, followed by dullness, with ir- 
regular spots of amphoric or tympanitic percussion note over the 
points of depression. 

Auscultation. First stage, vesiculo- bronchial, or harsh respira- 
tion, associated with large and small moist or bubbling, rales, followed 
by bronchial, broncho-cavernous, and cavernous respiration, with cir- 
cumscribed gurgling rales. 

Diagnosis. Beginning as a bronchial catarrh, slowly progressing, 
with the remission of the symptoms during the summer months, 
finally becoming progressively worse, the discovery of the bacilli in 
the sputum, with the formation of cavities, and symptoms of asthenia, 
are the chief points in the diagnosis. 

Prognosis. The duration of fibroid phthisis is most protracted, 
six to twelve years being the average duration ; death, however, is 
the inevitable termination. 

Prof. Da Costa has records of one hundred deaths from " grinders' 
consumption " whose average life was twelve years from the develop- 
ment of the signs of the disease. 

TREATMENT OF PULMONARY TUBERCULOSIS. 

Can pulmonary tuberculosis be prevented ? To a great extent, 
yes, as in a large proportion of cases the infection of the system is 
the result of contagion or the ingestion of food containing the germs 
in those having the inherited or acquired phthisical diathesis. It is 



342 PRACTICE OF MEDICINE. 

now known that tuberculosis is very common in the cattle whose 
flesh forms so large a portion of the food of man. Were it not for 
the protection given by cooking, the history of this disease would be 
a sadder one than it is. But the milk is not often cooked. May 
not the great increase in tuberculosis be caused by the use of cows' 
milk ? 

The bacilli once found in the sputum, can the unfortunate host be 
cured ? 

While I have never seen a case of marked incipient phthisis cured, 
in the broad acceptation of the term, I have repeatedly seen life pro- 
longed for a number of years, and the deposition of tubercle long 
delayed by a change of climate early in the history of the case, warm 
clothing, life and exercise in the open air short of fatigue, and sys- 
tematic bathing with a nutritious plan of dieting. If the diet is ar- 
ranged in accordance with the appetite, the latter will gradually 
increase, but should it not, it may be stimulated by such bitters as 
strychnines sulphas, nicx vomica, ignatia amara, Colombo, or gentian. 

For a number of years I have been in the practice of placing in- 
cipient cases of tuberculosis upon what I term " up and down " doses 
of strychnines sulphas, and often with a success that is amazing. A 
formula is given of — 

R. Stryckninse sulph., gr. iv .26 Gm. 

Aq. chloroformi, vel 

Ess. pepsini, f^ij 60. Cc. M. 

SlG. — Ten minims equal gr. Jj (0.0025 Gm.). 

Mode of using : Five drops three times daily for one week, then ten drops 
three times daily for a week, then fifteen drops three times daily for a week, 
then twenty drops three times daily for a week, then fifteen drops, then ten 
drops, then five drops, and so on week after week for months and years. 

The symptoms are to be met as they arise, and drugs are not to be 
used simply because the patient has the physical signs of beginning 
phthisis. For the general debility and malaise that accompanies the 
early stages of the malady, any one or a combination of the follow- 
ing drugs, exercising care that they in no way interfere with the 
appetite : Guaiacol, rr^iij-v (0.2-0.3 Cc.) for adults, and ™Jj-iij (0.12- 
0.2 Cc.) for children, four times daily, in either sweetened water, milk, 
or meat broth, or wine ; oleum morrhucz, ferri iodidum, hypophos- 



DISEASES OF THE LUNGS. 343 

phites, strychnines arsenias, gr. ^V" sV (0.001-0.002 Girt.) after meals, or 
a combination of arsenicum and digitalis : 

R. Acidi arseniosi, gr. j .065 Gm. 

Digkalini (Merck's), gr. j .065 Gm. M. 

Ft. pil. No. xxx. 

Sig. — One after meals. 

For the cough and expectoration, creosote, rt\j (0.06 Cc.) in milk, 
water, or whiskey three times daily, gradually increasing the dose a 
minim a day until stomach toleration. 

In the pneumonic variety the attempt should always be made to 
remove the caseous matter by absorption and expectoration. The 
following prescriptions will sometimes prove successful : 

&. Ammonii carb., . gr. v 

Ammonii iodidi, gr. v-x 

Aq. chloroformi, f^ij 

Syr. prun. virg., ........ f^ij 8. Cc. M. 

Every five hours, diluted, alternating with 



Liq. potassii arsenitis, Ttlv 

Mass. ferri carb., gr. v 

Vini xerici, f zj 

Aquae, q. s. ad fjss 15. Cc. M. 

In the tubercular variety the early dyspeptic symptoms are wonder- 
fully relieved by the following : 





3 Gm. 




3-. 6 Gm. 


8. 


Cc. 


8. 


Cc. 




3Cc. 




.3 Gm. 


4 


. Cc. 


15 


Cc. 



R . Pepsini cryst., gr. ij 

Acidi hydrochlorici dil., . . . . TTVxv I 

Glycerini, ... lTl x x I 

Succi limonis, l^xv I 

Aquae aurantii flor. , . . . . adfz,ij ad 8 
Sig. — With meals, diluted. 



13 Gm. 

Cc. 

3 Cc. 

Cc. 

Cc. M. 



It is in this variety of consumption that every means should be 
employed to improve the general health. Improvement may often 
follow the long continued moderate use of alcoholic stimulants, the 
amount being only such as will increase the appetite and improve 
the digestion. If rise of temperature, flushed face, or dyspeptic 
symptoms occur, discontinue the stimulants at once-. Be sure of the 
diagnosis before resorting to alcohol. 

For the fibroid variety, to prevent the hyperplasia of the connective 
tissue, hydrargyri corrosivum chloridum, polassii iodidum, or aurii et 
sodii chloridum, are recommended. Oleum morrhutz is of benefit. 



344 PRACTICE OF MEDICINE. 

For the gastric symptoms, which are often so severe as to seriously 
interfere with assimilation, either bismuthum, gr. xx (1.3 Gm.) before 
meals, or arsenicum : 

R . Liquor, potassii arsenitis, . . . TTLxxx 2. Cc. 

Tincturae nucis vomicae, . . . f 3] 4. Cc. 

Aquae chloroformi, . . . . adf^ij ad 60. Cc. M. 

Sig. — Teaspoonful before meals, diluted. 

For the fever, unfortunately, but little can be accomplished with 
drugs. If, however, it exceeds 101 F., an attempt should be made 
to reduce it. 

The " Niemeyer pill " is usually recommended, its formula being — 

R . Quinince sulph., gr. j .065 Gm. 

Pulv. digitalis, gr. ss .032 Gm. 

Pulv. opii, g r - X - OI 6 Gm. 

Pulv. ipecac, g r - X - OI ^ Gm. 

From a very considerable experience with this "famous " pill, I 
can recall few cases in which it has proven of the least benefit. The 
following is much more effectual : 

R. Quininae sulph. gr. x .6 Gm. 

Quininas muriat. , ...... gr. x .6 Gm. 

Pulv. opii et ipecac, gr. iij .2 Gm. 

Ft. capsul. No. ij. 

Sig. — One capsule five hours and the other three hours before the decided 
rise of temperature. 

In a few instances the temperature has been favorably influenced 
by antifebrin, gr. v (0.3 Gm.), in tablets, at one, three, and five 
o'clock each afternoon, or acetanilidum, gr. v (0.3 Gm.), at the same 
hours. If sweating occur, add to each five-grain tablet agaricin, 
gr. ^u (0.002 Gm.). Many patients prefer cool sponging, adding 
alcohol, vinegar, or bay-rum to the water, and there is no doubt 
that sponging will promptly reduce the temperature two or three 
degrees. 

For the cough the following may give relief: 

R. Codeince sulphat., gr. y^-Yz .022-032 Cm. 

Acidi hydrocyanici dil., rr\,ij .12 Cc. 

Syr. tolu, f£j 4. Cc. M. 

Sig. — Several times a day. 



DISEASES OF THE LUNGS. 345 

Or— 

R. Codeinae, gr. iv .26 Gm. 

Acid, hydrochlor. dil., ^3 SS 2 - Cc. 

Spirit, chloroformi, f^iss 6. Cc. 

Syr. limonis, f^j 30. Cc. 

Aq. lauro-cerasi, adf^iv ad 120. Cc. M. 

Sig. — A teaspoonful, repeated when cough is troublesome. 

If diarrhoea develop, bismuthum, gr. xx-xxx (1.3-2 Gm.) every 
three or four hours, with rest in bed and mustard to the abdomen ; 
or R. Cupri sulphat., gr. iss (0.1 Gm.); ext. nucis vomicae, gr. iij 
(0.2 Gm.) ; pulv. opii, gr. vj (0.4 Gm.). M. et ft. pil. No. xij. Sig. — 
One every three or four hours ; or R . Liquor, potassii arsenitis, rr^xxx 
(2 Cc.) ; tincturse opii deodorat., f^iss (6 Cc.) ; liquor pepsini, ad 
f^ij (60 Cc). M. Sig. — Teaspoonful at meal time. 

For night-sweats, atropine sulphas, gr. -^ (0.001 Gm.) at bed-time, 
or agaricin, gr. -fa-fa (0.003-0 006 Gm.) at bed-time, adding small 
doses of morphina if it cause loose stools. Camphoric acid, gr. xx- 
xxx (1.3-2 Gm.), about two hours before the expected sweat, the 
time of administration is important, as the drug is rapidly eliminated 
and it has the additional advantage of causing no ill or disagreeable 
effect. It is best given dry on the tongue, or in cachets. It is 
claimed that sulphonal, gr. v-x (0.3-0.6 Gm.), at bed-time, controls 
the night-sweats and also produces a quiet, refreshing sleep. 

For hemoptysis no one remedy is comparable with atropines 
sulphas, gr. ^tj~ ioo ~gV (Q-00032-0.00065-0.001 Gm.), repeated pro re 
nata ; or nitro-glycerinum, one per cent, solution, Tt\j (0.06 Cc), 
every fifteen minutes for a few doses, often acts promptly. 

Beginning in December, 1890, a large number of cases of incipient 
tuberculosis were treated in the wards of the Philadelphia Hospital 
with Koch's tuberculin. The treatment was negative in every case. 
In the fall of 1892 ten cases of early tuberculosis were placed under 
treatment with Kleb's tube7-culocidin. Its action is different from 
Koch's tuberculin in that it never excites the febrile reaction of the 
latter. The results were also negative, although for several months 
the patients seemed free from the bacillus. 

The diet must be of the most nutritious and easily digestible 
character. If oleum morrhua or petrolatum can be assimilated, 
either should be used for a long time. The hygiene of the patient is 
of the utmost importance, and, as it is a struggle for life, no means 
should be left untried to gain the victory. 
30 



346 PRACTICE OF MEDICINE. 



DISEASES OF THE PLEURA. 



PLEURITIS. 

Synonyms. Pleurisy ; " stitch in the side." 

Definition. A fibrinous inflammation of the pleura, either acute, 
subacute, or chronic in character, occurring either idiopathically or 
secondarily; characterized by a sharp pain in the side, a dry cough, 
dyspnoea, and fever. It may be limited to a part, or may involve 
the whole of one or both pleural membranes. 

Causes. Idiopathic pleuritis is said to be due to cold and expo- 
sure, to injuries of the chest walls, or the result of muscular exertion. 
Tuberculosis is the cause in a few instances. 

Secondary pleuritis occurs during an attack of pneumonia, pericardi- 
tis, rheumatism, variola, scarlatina, measles, Bright's disease, tuber- 
culosis, or puerperal fever. 

Chronic pleuritis follows an acute attack, or is the result of tuber- 
culosis, Bright's disease, cancer, or alcoholism. 

Pathological Anatomy. The ordinary course pursued by an 
inflammation of a serous membrane is hyperemia followed by exu- 
dation of lymph, the effusion of fluid, its absorption, and the adhesion 
of the membranes. 

The first or dry stage of pleuritis is a hyperaemia or diffused irreg- 
ular redness of the membrane, with little specks of exudation. The 
second stage is characterized by the copious exudation of lymph, more 
or less completely covering the membrane, giving it a dull, cloudy, 
or shaggy appearance. If the inflammation ceases at this point, it is 
termed dry pleuritis. The third, or stage of effusion, is characterized 
by the pouring out of a semi-fibrinous liquid, more or less completely 
filling and distending the pleural cavity, and floating in the fluid are 
fibrinous flocculi, blood, and epithelial cells. 

Absorption of the fluid and more or less of the exudative lymph 
soon occurs, the unabsorbed portion becoming organized, forming 
adhesions which obliterate the pleural cavity. 

The effusion, if on the right side, pushes the heart farther to the 
left; if on the left side, the heart is displaced to the right, the impulse 



DISEASES OF THE PLEURA. 347 

often being seen to the right of the sternum. The lungs are also 
compressed and displaced upward and against the spinal column, 
and, on removal of the fluid, expand again, except in cases of chronic 
pleuritis, when the functional activity of the pulmonary structure is 
more or less permanently impaired. 

Chronic pleuritis results when the fluid is not absorbed or when it is 
effused into the cavity in a slow and insidious manner. The mem- 
brane is irregularly thickened, with firm adhesions, fluid being 
found in the meshes; depressions of the thoracic walls also occur. 
The fluid may be serum, pus {empyema), or pus and blood. Open- 
ings may form, through which there is permanent discharge, either 
externally (fistulous empyema) or into the bronchi, or, rarely, into the 
bowels. 

Symptoms. Acute variety : Begins with a chill, followed by a 
sharp, lancinating pain (stitch) near the nipple or in the axilla, aggra- 
vated by coughing and breathing, associated with slight tenderness on 
Pressure. The respirations zxerapid and shallow, 30-35 per minute ; 
a short, dry, hacking cough ; mo&eraXQ fever ; compressible pulse, 90- 
120. With the effusion of liquid the dyspnoea becomes aggravated, 
the cough more distressing, the cardiac action embarrassed, \hz coun- 
tenance wearing an anxious expression, the patient usually lying on 
the affected side. With the absorption of the fluid the symptoms 
gradually ameliorate, convalescence being more or less rapid. 

Subacute variety : Begins insidiously after cold, exposure, and 
fatigue in those enfeebled. Patients usually complain of a sense of 
weariness, shortness of breath, aggravated on exertion, evening fever, 
followed by night-sweats, short harassing cough, none or very scanty 
sputum; the pulse is small, feeble, but frequent, 100-120 beats per 
minute. The characteristic pain in the side is usually wanting. 

Chronic variety : Irregular chills, fever, night-sweats, dyspnoea, 
palpitation, embarrassed circulation, with more or less prostration. 

Inspection. First stage, deficient movement of the affected side, 
on account of the pain induced by full breathing. 

Second stage, bulging or fullness of the affected side, with oblitera- 
tion of the intercostal spaces and displacement of the cardiac im- 
pulse. 

Palpation. Second stage, vocal fremitus feeble or absent over 
the site of the effusion, exaggerated above the site of the fluid. 
Rarely, fluctuation may be obtained. 



348 PRACTICE OF MEDICINE. 

Percussion. First stage ; may be slightly unpaired. 

Second stage • dullness or even flatness over the site of the effusion ; 
ty?npajiitic percussion note above the fluid. 

Auscultation. First stage; feeble vesicular murmur over the 
affected side, the patient breathing superficially, to prevent the pain ; 
a friction sound, slight and grating or creaking, becoming louder as 
the exudation of lymph increases, limited usually to the angle of the 
scapula of the affected side, rarely heard over the entire side, accom- 
panies the respiratory movements. 

Second stage ; feeble or absent vesicular murmur on the affected 
side, depending upon partial or complete compression of the lungs 
by the fluid. Above the fluid puerile breathing, and just at the upper 
margin of the fluid a friction sound may be heard. 

The vocal resonance \s diminished or absent over the site of the 
fluid and markedly increased above, cegophony being present at the 
upper margin of the fluid. 

With the absorption of the fluid the vesicular murmur gradually 
returns, associated with a moist friction sound. 

Diagnosis. Acute pneumonia is often mistaken for the effusion 
stage of pleurisy. The points of distinction are : in pneumonia there 
is the pronounced chill, high fever, and characteristic sputa, bronchial 
breathing, exaggerated vocal fremitus and resonance, and no displace- 
ment of the heart, the reverse occurring in pleurisy. 

Enlargement of tJie liver may be mistaken for pleurisy with effu- 
sion, the chief point of distinction being that, in enlargement of the 
liver, the superior line of dullness is depressed upon full inspiration, 
while in pleurisy with effusion inspiration does not modify the loca- 
tion of the dullness. 

Prognosis. Idiopathic pleurisy usually terminates in recovery 
within three weeks. Pleurisy the result of constitutional causes has 
its prognosis modified by the condition with which it is associated. 
Empyema, unless the result of a diathesis, terminates favorably. 
Double pleurisy is unfavorable. The etiological factor of tuberculosis 
must always be borne in mind in making a prognosis in pleurisy, 
whether acute or chronic. 

Treatment. At the onset, in plethoric patients, wet cups over the 
affected side ; if great dyspnoea, severe pain, and high arterial tension, 
even venesection, and in anaemic or weak persons, dry cups, follow- 
ing the use of either wet or dry cups with poultices or turpentine 



DISEASES OF THE PLEURA. 349 

stupes. The severe pain is promptly relieved by the hypodermic in- 
jection of morphince sulphas, over its site, repeated as indicated, or 
the frequent use of small doses of pulvis ipecacua7ihce et opii. 

In the very early stages of pleurisy the disease maybe cut short by 
sodiisalicylas, gr. xv-xx (i— 1.3 Gm.), well diluted every three or four 
hours. In the stage of effusion excellent results follow the use of the 
salicylates. 

After effusion has begun, ex trac turn pilocarpi Jluidu7n,V(\ j xv (1 Cc), 
every two or three hours, or in drachm doses every other day for a 
week or two, after which twice weekly ; or — 

R. Pota^sii acetat., gr. xxx 2. Gm. 

Infus. digitalis, f^ij 8. Cc. M. 

Every three or four hours. 

Bowditch, of Boston, for years has advocated early aspiration in 
pleural effusion. If after three or four days no impression is made 
on the effusion by drugs, aspiration should be employed and table- 
spoonful doses of liquor fei'ri etammonii acetatis (Bashatns mixture) 
administered every four hours, and an early morning dose of mag- 
nesii sulp/ias, ^ss-j (15-30 Gm.) well diluted. 

The effusion of pleuritis is rapidly removed by the method of treat- 
ment suggested by Prof. Matthew Hay, of Scotland, consisting in the 
use of a concentrated solution of saline cathartics : " Order the patient 
to take nothing after the evening meal, and then an hour or so before 
breakfast the salt is given dissolved in as little water as possible. 
Usual dose from 3iv-vj (15-24G1T1.) to ^j-ij (30-60 Gm.) magnesiisul- 
phatis to an ounce or two of water, no fluids to be used after the dose ; 
this usually produces from four to eight watery stools, without pain or 
discomfort, and also acts as a diuretic." 

The essence of the " Hay method " consists in getting the concen- 
trated solution into the intestines at a time when the fluid contents 
are scanty. 

If the effusion is uninfluenced by the above-named means, use 
potassii iodidum, gr. xv(i Gm.), every four hours, well diluted, with 
flying blisters over the affected side, or unguentum hydrargyri in the 
arm-pits, groins, and over the site of the effusion. 

In double pleuritic effusion, evacuate the fluid at once with the aspi- 
rator, and use the potassium and digitalis mixture mentioned above. 

Chronic pleurisy. If the effusion be still serous, it is often absorbed 



350 PRACTICE OF MEDICINE. 

by the internal use of potassii iodidum, alternating with "Bas/iam's 
mixture" and blisters, the secretions being watched. If, however, 
the liquid is pus {empyema), the aspirator should be used at once, the 
patient placed upon " Basham 's mixture," stimulants, and quinince 
hydrochloras. 

Usually, however, within a very few days after aspiration, another 
accumulation of pus will have taken place. Should this occur, the 
purulent pleurisy should then be treated as an abscess, an incision 
being made between the fifth and sixth ribs, the pus evacuated, a 
drainage-tube introduced, and an antiseptic dressing applied. If the 
tendency to pus secretion still remains, the pleural cavity must be 
washed out with an antiseptic solution, the constitutional treatment 
being continued. 

HYDROTHORAX. 

Synonym. Dropsy of the pleura. 

Definition. The effusion of fluid into the pleural cavities (bilat- 
eral), the result of a general dropsy from renal or cardiac disease. 

Pathological Anatomy. More or less clear serous fluid in 
both pleural sacs, compressing the lung. No signs of inflammation 
are present. 

Symptoms. Following dropsy of the abdomen occurs dyspnoea, 
with signs of deficient blood aeration, both lungs being compressed. 

Palpation. Absent vocal fremitus over the site of the fluid. 

Percussion. Dullness over the site of the fluid. 

Auscultation. Absent vesicular murmur over the site of the fluid. 

Diagnosis. Easily determined by association of the symptoms 
with a general dropsy. 

Prognosis. Controlled by the cause producing the general dropsy. 

Treatment. Depending upon the condition causing the dropsy. 
Dry cups over the chest afford relief. If the symptoms of non- 
aeration of the blood are severe, the fluid should be at once evacuated 
with the aspirator. 

PNEUMOTHORAX. 

Synonyms. Air in the pleural cavity ; hydropneumothorax. 
Definition. The accumulation of air in the pleural cavities, with 
the consequent development of inflammation of the membranes; 



DISEASES OF THE PLEURA. 351 

characterized by sharp pain, followed by rapidly developing dyspnoea 
and cough. 

Causes. Generally the result of tuberculosis, causing perfora- 
tion of the pleura. Perforation may take place from the pleura 
into the lung, in connection with empyema or abscess of the chest 
wall. Direct perforation from without, by laceration of a fractured 
rib or severe contusion. 

Pathological Anatomy. The gas in the pleural cavity consists 
of oxygen, carbon anhydride, and nitrogen in variable proportions. 
It may fill the pleural sac completely, compressing the lung, or is 
sometimes limited by adhesions. The gas tends to excite inflamma- 
tion, the resulting effusion being either serous or purulent. 

Symptoms. Symptoms of pneumothorax, the result of perfora- 
tion, are sudden or sharp pain in the side, intense dyspnoea, attended 
with symptoms of collapse, coldness of the surface, and cold sweats. 

The above symptoms, in many instances, follow a severe or violent 
paroxysm of coughing. In severe cases there is never a moment's 
cessation of the acute pain and distressing dyspncea, causing orthop- 
ncea from the onset until death. 

Inspection. Enlargement of the affected side, the intercostal 
spaces being widened and effaced or even bulged out so that the 
surface of the chest is smooth. Respiratory movements of the affected 
side are diminished or absent. 

Percussion. Immediately after the rupture the percussion note 
is hyper-resonant, or even tympanitic or amphoric in quality. If the 
amount of air in the pleural cavity becomes extreme, there is dullness 
on percussion, associated with a feeling of great resistance or density. 
When effusion of blood occurs, dullness is observed over the lower 
part of the chest, hyper-resonant or tympanitic percussion note over 
the upper portions of the chest, these sounds changing as the patient 
changes position. 

Auscultation. The normal vesicular murmur may be diminished 
or absent. The typical amphoric respiratory sound is heard when 
the fistula is open, usually associated with a metallic echo. 

Metallic tinkling, or the bell sound, is sometimes distinctly pro- 
duced by breathing, coughing, or speaking, after the development of 
inflammation of the pleura. 

The vocal resonance may be diminished or absent, or, rarely, it 
may be exaggerated, with a distinct metallic echo. 



352 PRACTICE OF MEDICINE. 

After the development of inflammation in the pleura, suddenly 
shaking the patient gives rise to a splashing sensation, the succussion 
sound, if both air and fluid are present in the pleural cavity. 

Prognosis. When occurring as the result of tuberculosis, the 
prognosis is extremely unfavorable ; rarely, the fistulous opening 
is closed by inflammatory action ; the case then becomes one of 
chronic pleurisy. 

Treatment. At once a hypodermic injection of morphince sul- 
phas, which relieves the severe pain and somewhat modifies the dis- 
tressing dyspnoea, followed by the evacuation of the fluid and air 
with the aspirator. 

If the fistulous opening be closed by inflammatory action, the case 
resolves itself into one of chronic pleurisy, the treatment indicated for 
that affection plus the treatment of tuberculosis, being the indication. 



DISEASES OF THE CIRCULATORY 
SYSTEM. 



The methods employed in making a physical examination of the 
heart are : I. Inspection. II. Palpatio?i. III. Percussion. IV. Aus- 
cultation. 

Inspection indicates the exact point of the cardiac impulse, and 
the presence or absence of any abnormal pulsations or any change in 
the form of the pracordium. 

Normally the impulse is visible only in the fifth interspace, midway 
between the left nipple and the left border of the sternum, its area 
covering about one square inch, most distinct in the thin, while often 
barely seen in the very fleshy ; often displaced downward by full in- 
spiration and elevated by complete expiration. 

Disease may alter the position and area of the impulse. 

The position of the impulse is moved to the right by left pleuritic 
effusions ; downward by cardiac hypertrophy or pulmonary emphy- 
sema ; upward by a pericardial effusion. 

The area of the impulse is changed and enlarged by pericardial 
adhesions, cardiac dilatation or hypertrophy. • 



DISEASES OF THE CIRCULATORY SYSTEM. 353 

Palpation confirms the observations of inspection, and also deter- 
mines the force \ frequency , and regularity of the cardiac impulse. 

The force of the impulse is diminished by cardiac dilatation, fatty 
and fibroid degenerations of the heart, emphysema, pericardial effu- 
sion, and adynamic diseases. 

The impulse is increased by cardiac hypertrophy, during the first 
stage of endocarditis and pericarditis, functional cardiac disturbances, 
and sthenic inflammations. 

Percussion will determine the boundaries of the superficial and 
deep cardiac space, the so-called prcEcordium. It is essential that the 
upper, lower, and two lateral boundaries of the pericardial region be 
memorized, to wit : superior boundary, the upper edge of the third 
rib ; the lower boundary is a horizontal line passing through the fifth 
intercostal space ; the left lateral boundary is about or a little within 
a vertical line passing through the nipple, the linea mammalis ; and 
the right lateral boundary is an imaginary vertical line situated one- 
half an inch to the right of the sternum. These boundaries vary some- 
what in health, but are sufficiently accurate for all practical purposes. 

The superficial cardiac space represents that portion of the heart 
uncovered with lung ; it is triangular in form, its apex being the junc- 
tion of the lower border of the left third rib with the sternum, its area 
not exceeding two inches in any direction. 

The superficial space is increased by cardiac hypertrophy, dilata- 
tion, or pericardial effusion. 

Diminished at the end of full inspiration or by emphysema. 

The deep cardiac space represents that portion of the heart covered 
by lung, and extends from the upper border of the third rib to the 
lower edge of the fifth interspace, and from half an inch to the right 
of the sternum to near the left nipple. 

It is increased by hypertrophy or dilatation of the heart, left pleuritic 
effusion, and apparently increased by consolidation of the anterior 
border of the investing lung. 

Auscultation indicates the character of the normal cardiac 
sounds and the point at which they are heard with greatest intensity, 
and should be thoroughly familiarized if abnormal sounds are to be 
fully appreciated. 

The ear or stethoscope applied to the praecordium distinguishes in 
health two sounds, separated by a momentary silence — the short 
pause, and the second sound followed by an interval of silence — the 
long pause. 



354 



PRACTICE OF MEDICINE. 



The first sound, corresponding to the contraction of the heart — the 
systole — is louder, longer, and of a lower pitch and a more booming 
quality than the second sound, and has its point of greatest intensity 
at the cardiac apex or a little to the left. It corresponds closely in 
time to the pulsations as felt in the carotid or radial arteries. 

The second sound is shorter, weaker, and higher in pitch than the 
first sound, and has a clicking or valvular quality, having its point of 
greatest intensity at the second right costal cartilage and a little above, 
and corresponds to the closure of the aortic and pulmonary valves. 
The sound made by the closure of the tricuspid valves is best isolated 
at the ensiform cartilage ; the sound made by the closure of the 
pulmonary valves, at the third left costal cartilage. 

The following table, giving the phenomena and time of normal 
cardiac movements, will assist in recalling the physiology of the 
heart : 



Systole of the 
heart, or 
ventricular 
systole. 



Action of Heart. 

Ventricles contracting, 
auricles dilating. 

Auriculo-ventricular valves 
(mitral and tricuspid) sud- 
denly close and remain 
closed during the whole 
time of the first sound. 

Semilunar valves (aortic 
and pulmonary) open ; 
movement or locomotion of 
heart causing the impulse or 
apex beat. 

Blood rushes out from the 
ventricles into aorta and 
pulmonary artery, and di- 
lates these vessels and their 
extensions (arterial system). 

Blood flows slowly into 
the auricles from the vena 
cava and pulmonary veins. 

The pulse felt in different 
arteries from one-thirtieth to 
one-eighth of a second later 
^ than impulse. 



Sound 

and Pause. 



First car- 
diac sound 
> (systolic 
dull and 
prolonged 



Time in One- 
tenths of the 
Heart's Beats. 



) !- 



About four- 
tenths of the 
heart's beats, 
or twenty- 
four-sixtieths 
of a second. 



DISEASES OF THE CIRCULATORY SYSTEM. 



355 



Diastole of the 
heart, or 
ventricular 
diastole. 



Action of Heart. 

Ventricles dilating and re- 
ceiving blood from auricles. 
Auricles dilating and receiv- 
ing blood from veins. 

Auriculo-ventricular valves 
(mitral and tricuspid) open. 

Dilated pulmonary artery 
and aorta recoil and sud- 
denly close the semilunar 
valves (aortic and pulmonic), 
which remain closed during 
the whole of the second 
sound and the interval of 
silence. 

Ventricles and auricles 
still continue to dilate — viz. , 
receive blood. Near the 
close of this period the auri- 
cles, being fully dilated (filled 
with blood), suddenly con- 
tract and complete the dila- 
tation of the ventricles. 



Sound 
and Pause. 



Time in One- 
tenths ok the 
Heart's Beats. 



Second 


About three- 


cardiac 


tenths of the 


sound 


heart's beats 


(diastole) 


or eighteen - 


short and 


sixtieths of 


sharp. 


a second. 



Period of 

silence or 

rest. 



About three - 

tenths of the 

heart's beats, 

or eighteen- 

sixtieths of 

a second. 



The extent of surface over which the cardiac sounds are heard 
varies, according to the size of the heart and the condition of the 
adjacent organs for transmitting sounds. 

The cardiac sounds may be altered in intensity, quality, pitch, seat, 
and rhythm, or they may be accompanied, preceded, or followed by 
adventitious or new sounds, the so-called endocardial or cardiac ?nur- 
murs. 

The intensity is increased 'by cardiac hypertrophy, irritability of the 
heart, or consolidation of adjacent lung structure. 

The intensity is diminished \>y cardiac dilatation or degeneration, 
during the course of adynamic fevers, emphysematous lung over- 
lapping the heart, or pericardial effusion. 

The quality and pitch of the first sound may be sharp or short and 
of higher pitch when the ventricular walls are thin, or have under- 
gone beginning fibroid change, the valves being normal ; its pitch 



356 PRACTICE OF MEDICINE. 

and quality are also raised during the course of low fevers. The 
second sound becomes duller and lower in pitch when the elasticity 
of the aorta is diminished or the aortic valves thickened. Either or 
both sounds have a more or less metallic quality in irritable heart 
and during gaseous distention of the stomach. 

The seat of greatest intensi'y of the cardiac sounds is changed by 
displacement of the heart, pleuritic effusion, pericardial effusion, and 
abdominal tympanites. 

The rhythm is often interrupted by a sudden pause or silence, the 
heart missing a beat, or the sounds are irregular, confused, and tumul- 
tuous, the result of organic changes in the cardiac muscle, valves, 
orifices, or vessels ; or a reduplication of one or both sounds of the 
heart may occur. 

The adventitious cardiac sounds or murmurs are of two kinds : those 
made external to the heart, as pericardial, exocardial, or frictional 
murmurs, and those made within the cardiac cavity, endocardial 
7nurmurs. 

Pericardial murmurs, or friction sounds, are made by the rubbing 
upon one another of the roughened surfaces of the pericardial mem- 
brane during the early stages of inflammation. The sounds have a 
rubbing, creaking, or grating character, and are differentiated from 
a pleural friction sound by their being limited to the praecordium, 
synchronous with every sound of the heart, and not influenced by 
respiration. 

They are distinguished from an endocardial murmur by their super- 
ficial rubbing, creaking, or grating character, and by not being trans- 
mitted beyond the limits of the heart, either along the course of the 
vessels, or to the left axilla or back. 

Endocardial murmurs are of two kinds — to wit : organic and func- 
tional. 

Functional endocardial or blood murmurs are the result of changes 
in the normal constituents of the blood. 

Their character is soft, they are heard most distinctly at the base to 
the left of the sternum, during the systole, are not transmitted beyond 
the limits of the heart, either to the left axilla or the back, and they 
are associated with general anaemia. 

Organic endocardial murmurs are produced by blood currents pur- 
suing either a normal or an abnormal direction. 

In health there are two direct blood currents upon each side of the 



DISEASES OF THE CIRCULATORY SYSTEM. 357 

heart — to wit : the current from the left auricle to the left ventricle, the 
mitral direct current; the current from the left ventricle to the aorta, 
the aortic direct current; the current from the right auricle to the right 
ventricle, the tricuspid direct current ; and the current from the right 
ventricle to the pulmonary artery, the pulmonic direct cut rent. 

When, from disease, the valves are not properly closed, the blood 
is allowed to flow back against the direct current, producing abnormal 
blood currents — to wit : when the mitral valve is incompetent, the 
blood flows from the left ventricle back into the left auricle during the 
cardiac systole, producing the mitral regurgitant or indirect current ; 
when the aortic valves are incompetent, the blood is permitted to 
flow from the aorta into the left ventricle during the cardiac diastole, 
producing the aortic regurgitant or indirect current ; when the tricus- 
pid valves are incompetent, the blood flows from the right ventricle 
back into the right auricle during the systole, producing the tricus- 
pid regurgitant or indirect current ; when the pulmonary valves are 
incompetent, the blood flows from the pulmonary artery into the right 
ventricle, producing the pulmonic regurgitant or indirect current. 

The mitral direct current occurs during the contraction of the left 
auricle, or just before the first sound of the heart and immediately 
after its second sound. The aortic direct current is produced by the 
contraction of the left ventricle, and occurs with the first sound of the 
heart. The tricuspid direct curre?it occurs during the contraction of 
the right auricle, or just before the first or immediately after the 
second sound. The pulmonic direct current is produced by the con- 
traction of the right ventricle, occurring during the first cardiac sound. 

The mitral direct or presystolic murmur occurs before the first 
sound of the heart and immediately after the second sound. It is 
caused by a narrowing of the mitral orifice, has a blubbering quality, 
well imitated by throwing the lips into vibration by the breath, of a 
low pitch, and it has its seat of greatest intensity at the cardiac apex, 
and is not transmitted to the left axilla or to the base of the heart. 

The mitral regurgitant or systolic murmur occurs with the first 
sound of the heart, resulting from the failure of the mitral valves to 
close the mitral orifice during the systole, in consequence of which 
the blood flows back, or regurgitates into the left auricle. It is usually 
of a blowing or churning character, and has its seat of greatest in- 
tensity at the cardiac apex, being well transmitted to the left axilla 
and inferior angle of the left scapula. 



358 PRACTICE OF MEDICINE. 

The aortic direct murmur occurs with the first sound of the heart. 
It is caused by a narrowing of the aortic orifice, has a rough or creak- 
ing character, is of high pitch, having its seat of greatest intensity in 
the second intercostal space, to the right of the sternum, and is well 
transmitted over the carotid artery. 

The aortic regurgitant 7>iurmur occurs with the second sound of the 
heart, and is caused by the failure of the aortic valves to close the 
aortic orifice during the diastole, permitting the blood to flow back 
or regurgitate into the left ventricle. It is usually of a blowing or 
churning character and of low pitch, having its seat of greatest in- 
tensity over the base of the heart, and is well transmitted downward 
toward or below the cardiac apex. It is the only organic murmur 
heard in the left side of the heart which occurs with the second 
sound of the heart. 

The tricuspid di}'ect murmur occurs before the first sound of the 
heart and immediately after the second sound. It is caused by a nar- 
rowing of the tricuspid orifice, has a blubbering quality, and is low 
in pitch, having its seat of greatest intensity near the ensiform carti- 
lage. This murmur is exceedingly rare. 

The tricuspid regurgitant murmur occurs with the first sound of 
the heart, the result of the failure of the tricuspid valves to close the 
tricuspid orifice during the systole, thus allowing the blood to flow 
back or regurgitate into the right auricle. It is usually of a blowing 
or soft, churning character, having its seat of greatest intensity at 
the ensiform cartilage. This murmer is also very infrequent, and 
occurs mostly when the right ventricle is considerably dilated, and 
without the existence of any valvular disease. 

The pulmonic direct murmur occurs with the first sound of the 
heart. It is generally connected with congenital lesions. It occurs 
at the same instant that the aortic direct murmur occurs, and is dis- 
tinguished from the latter by its not being transmitted into the carotid 
artery, whereas the aortic direct murmur is always thus transmitted. 

The pulmonary regurgitant murmur occurs, like the aortic regurgi- 
tant murmur, with the second sound of the heart. This murmur is 
exceedingly rare, and its presence is only positively differentiated 
from the aortic regurgitant murmur by the absence of aortic lesions 
and symptoms. 



DIbEASES OF THE CIRCULATORY SYSTEM. 359 

ACUTE PERICARDITIS. 

Definition. An acute fibrinous inflammation of the pericardium ; 
characterized by slight fever, pain, precordial distress, and disturbed 
cardiac action and circulation. 

If the inflammation be limited to the parietal or visceral layer, or 
to a part of either, it is termed partial or circumscribed pericarditis; 
if it involve the whole of both surfaces, it is termed general or diffused 
pericarditis. 

The inflammation may be primary or secondary. 

Causes. Primary pericarditis resulting directly from cold and 
exposure or injuries is rare. 

Secondary pericarditis follows, or is associated with, rheumatism, 
influenza, scarlatina, variola, puerperal fever, tuberculosis, septicaemia, . 
Bright's disease, gout, scurvy, and diabetes. 

It is frequently associated with pneumonia and pleuro-pneumonia, 
particularly in alcoholics. 

Pathological Anatomy. The same as of serous membranes 
in other situations. The morbid changes maybe seen as (i) acute 
plastic or dry pericarditis (frequently tubercular) ; (2) pericarditis 
with effusion, sero-fibrinous, hemorrhagic, or purulent. 

Hypercemia of the membrane, most marked on the visceral layer, 
followed by the exudation of lymph scattered in irregular patches, 
giving it a rough and shaggy appearance {dry pericarditis), followed 
by the effusion of a sero-fibrinous fluid, with flocculi floating in it, 
and at times mixed with blood. Rarely, the fluid is purulent. 

The fluid and lymph undergo absorption with resulting adhesions 
identical with those described under pleurisy. 

Symptoms. Acute pericarditis may be well marked and still 
present none of the characteristic subjective symptoms. It usually 
begins with rigors, fever of the remittent type, frequently nausea and 
vomiting, precordial distress and tenderness, acute shooting pains, in- 
creased by breathing and coughing ; dry, suppressed cough ; increased 
cardiac action, and sometimes violent palpitation. An attack of peri- 
carditis secondary to an existing disease presents no marked symp- 
toms other than those mentioned to indicate its onset. Attacks of 
nausea and vomiting occurring during the course of rheumatism, 
pneumonia, pleurisy, and nephritis should call attention to the heart. 
Duration of this early stage, from a few hours to a day or two. 



3G0 PRACTICE OF MEDICINE. 

Effusioii stage : The symptoms of this stage are in keeping with the 
amount and rapidity of the effusion : precordial oppression, tendency 
to syncope ; dyspnoea, sometimes amounting to orthopncea ; dysphagia, 
hiccough, nausea and vomiting ; feeble, irregular pulse; sometimes 
either melancholia, delirium, or acute maniacal excitement. 

Absorptio?i is generally rapid, the heart remaining " irritable " for a 
long time after. If instead of absorption the fluid accumulates and 
life is not destroyed, the pericardial sac becomes dilated, chronic 
pericarditis resulting. 

Inspection. Early stage, excited cardiac action is evidenced by 
the impulse. 

Effusion stage, feeble, undulatory, or absent impulse ; its position 
displaced upward, or, rarely, downward; bulging of the praecordium 
and protruding abdomen if effusion be large. 

Palpation. Early stage, excited or tumultuous impulse ; peri- 
cardial friction fremitus rare. 

Effusion stage, feeble or absent impulse, and if present, its position 
is changed. 

Percussion. Early stage, normal. 

Effusion stage, cardiac dullness, enlarged vertically and laterally, 
and, if considerable fluid, of a triangular shape, with the base of the 
triangle on a line with the sixth or seventh rib, extending fiom the 
right of the sternum to the left of the left nipple, narrowing as it pro- 
ceeds upward to the second rib, or above, which represents the apex 
of the triangle. The shape of the dullness is sometimes altered by 
changing the position of the patient. 

Auscultation. Early stage, excited cardiac action, and usually 
afriction sound (exoca.rd'ia.1 murmur) synchronous with cardiac sounds 
and uninfluenced by respiration, but often increased by pressure with 
the stethoscope. 

Effusion stage, cardiac sounds feeble and deep-seated at the cardiac 
apex, becoming louder and distinct toward the cardiac base. The 
friction sound is sometimes heard at the cardiac base. 

If absorption occur, the above signs gradually give place to the 
normal, the friction sound returning, of a churning, or clicking, or 
grating character, gradually disappearing. 

Diagnosis. Endocarditis is often confounded with pericarditis, 
the points of distinction between which will be pointed out when dis- 
cussing that affection. 



DISEASES OF THE CIRCULATORY SYSTEM. 361 

Cardiac hypertrophy or dilatation is sometimes confounded with 
pericardial effusion ; the differences between which will be pointed 
out when discussing those affections. 

Hydropericardium may be mistaken for pericardial effusion ; see 
that affection. 

Prognosis. Controlled by the severity of the inflammation, 
causes, and coexisting affections. There is no doubt but that peri- 
carditis with slight effusion is frequently overlooked. If slight 
effusion, favorable. Death has quickly occurred when a large 
quantity of fluid has been rapidly effused, the patient being really 
drowned in his own fluid. Adherent pericardium is a frequent 
sequela. 

Treatment. Perfect rest in bed with absolute mental quiet. 
Death has followed neglect of this precaution, and particularly during 
the stage of effusion. 

The important indications for treatment are to limit the inflamma- 
tory action and quiet the heart in the first stage, and to promote 
absorption and prevent cardiac failure in the second stage. 

Local applications in the early stage are most valuable ; for vigor- 
ous patients, the application of leeches or wet cups to the prsecordium, 
followed by the application of ice poultices or iced compresses ; in the 
feeble, dry cups in the praecordium, followed by poultices. 

For the gastro-intestinal symptoms calomel is indicated, and it may 
have a beneficial effect on the inflammatory action : 

R. Hydrargyri chloridi mitis, . . gr. y^ .022 Gm. 

Sodii bicarbonat. , gr. ij .13 Gm. 

Sacchar. lactis, gr. ij .13 Gm. 

Dry on tongue every two hours until free action. 

The late Dr. Pepper said the " following combination is often very 
acceptable" : 

R • Pulv. digitalis, 

Mass. hydrargyri, . . . . aa gr. x aa .6 Gm. 

Pulv. opii, gr. v .3 Gm. 

Quininse sulph., gr. xxx 2. Gm. 

Ft. mass et div. in pil. No. xx. 

Sig. — One pill three or four times daily. 

In young, vigorous patients, early in the disease control the excited 
cardiac action by small doses of aconitwn or veratrum viride ; in the 
31 



362 PRACTICE OF MEDICINE. 

adult, aged, or feeble using digitalis ; in all cases qui?iincz sulphas or 
hydrochloras is indicated. Avoid all cardiac sedatives in secondary 
cases save those following rheumatism. 

If pain is severe during the pre-effusion stage, pulvis ofiii et ipe- 
cacuanha or morphintz sulphas may be cautiously used. 

Effusion stage : As the effusion progresses, the free administration 
of alkalies — to wit : ammonii carbonas, gr. v (0.3 Gm.) every two hours, 
with liquor ammonii acetatis, or potassii acetatis, or potassii carbonatis, 
with quinince sulphas or hydrochloras, nutritious liquid diet and stimu- 
lants, being cautious with the use of cardiac sedatives or tonics. 

If the pericarditis is secondary, the general treatment of such con- 
dition must be continued. 

If the effusion has a tendency to linger, blisters to the prascordium 
and potassii iodidum should be used, and if the symptoms of oppres- 
sion are marked or the effusion linger, paracentesis is indicated. Dr. 
Roberts, in his monograph, gives an account of sixty cases of para- 
centesis with twenty-four recoveries. He advises that the tapping be 
done in the fossa between the ensiform and costal cartilages on the 
left side, or in the fifth left interspace near the junction of the sixth 
rib with its cartilage. 

Dr. Tyson recommends the use of a blister as soon as the diag- 
nosis is determined. He says : " There is no other disease in which 
I am so satisfied of the efficiency of a blister ; it helps to prevent 
effusion and also to promote the absorption of effusion." 

The diet must be nutritious and easy of digestion throughout the 
disease. If evidence of cardiac failure, use strychnince sulphas, gr. ^ 
(0.0025 Gm.), hypodermically. three or four times daily. 



CHRONIC PERICARDITIS. 

Synonym. Adhesive pericarditis. 

Definition. A chronic inflammation of the pericardium, with 
either distention of the sac by fluid or adhesions of the pericardium 
(adherent pericardium) ; characterized by impaired cardiac action 
and disturbances of the circulation. 

Causes. Almost always the result of an acute attack. The line 
of demarcation between the acute and chronic forms is not sharp. 

Pathological Anatomy. If the effusion be absorbed, the peri- 
cardial surfaces are agglutinated by several layers of lymph, which 



DISEASES OF THE CIRCULATORY SYSTEM. 363 

increase the thickness of the membranes half an inch or more, and 
the outer surface of the pericardium becomes adherent to the chest 
walls. 

If the fluid is not absorbed, it may progressively accumulate, dis- 
tending the sac in all directions, displacing the diaphragm and inter- 
fering with the functions of the surrounding viscera, or a low grade 
of inflammation supervenes, the fluid becoming purulent (empyema 
of the pericardium), the disease terminating fatally after a variable 
period. 

As much as eight to ten pints of fluid have accumulated in the sac. 

Symptoms. Precordial pain and distress ; irregular, feeble car- 
diac action ; dyspnoea, aggravated by movement, and disturbed circu- 
lation. 

An agglutinated pericardium seriously increases the danger from 
an attack of any pulmonary inflammation. 

Inspection. If the effusion be present, bulging of the praecor- 
dium and displacement of the impulse. 

If adhesions are formed between the pericardial surfaces as well as 
with the chest walls, inspection reveals depression of the firczcordium, 
narrowing of the spaces, increased extent but displaced impulse, un- 
influenced by deep inspiration, and recession of the intercostal spaces 
{systolic dimpling) and epigastrium with every systole of the heart, 
the result of the adhesions. 

Palpation. If effusion, displaced, feeble, or absent impulse ; if 
adhesions, displaced and tumultuous impulse ; occasionally a peri- 
cardial fremitus is distinguished. 

Percussion. If effusion, the dullness has more or less the char- 
acter described for acute pericarditis. 

If adhesions, the cardiac dullness is but slightly modified. 

Auscultation. If effusion, cardiac sounds feeble and deep-seated 
at the apex, louder and more distinct at the cardiac base. 

If adhesions, cardiac sounds are heard with equal distinctness in 
their several positions, associated with a rough friction sound (exo- 
cardial murmur). 

Treatment. If effusion, blisters to the praecordium, with potassii 
iodidum to hasten absorption, the patient being supported by nutritious 
diet, quinines sulphas, ferrum and stimulants, and perfect quiet. If 
these means fail to remove the fluid, or if the fluid be purulent, para- 
centesis should be performed at once. 



364 PRACTICE OF MEDICINE. 

If adhesions of the pericardium have resulted, the application of 
blisters to the praecordium, with the administration of potassii iodidum, 
alternating with ferrum and quinince hydrochloras, are indicated, with 
nutritious diet, stimulants, and perfect quiet. 



HYDRO-PERICARDIUM. 

Synonym. Pericardial dropsy. 

Definition. The accumulation of water in the pericardial sac, 
minus inflammation ; characterized by prascordial distress, disturbed 
cardiac action, dyspnoea, and dysphagia. 

Causes. Usually a part of a general dropsy ; Bright's disease; 
sudden pneumothorax ; pressure of an aneurism or other mediastinal 
tumor ; disease or thrombosis of the cardiac veins. 

Pathological Anatomy. The fluid may range in quantity from 
an ounce to one or two pints, and is of a clear, yellowish or straw- 
colored serum, at times turbid or bloody, and of an alkaline reaction. 

If the amount of fluid be large, the sac is dilated, its walls thinned 
by the pressure, and has a sodden appearance. 

Symptoms. Dropsy of the pericardium is so generally associated 
with hydrothorax or dropsy of the pleurae that the symptoms are but 
an aggregation of those attending upon that condition — to wit : dis- 
tu?'bed cardiac action, dyspncea, dysphagia, dry cough, and feeble cir- 
cu!atio7i. 

The physical signs are exactly those of the stage of effusion of 
pericarditis, minus a friction sound. 

Diagnosis. Pericarditis with effusion and hydro-pericardium 
present nearly the same signs and symptoms, a differentiation being 
possible only by a history of the case and the symptoms of the attack. 

Prognosis. Controlled entirely by the cause. 

Treatment. Depends upon the cause of the attack. If the 
amount of fluid in the pericardial sac be great, paracentesis will give 
relief. 

ACUTE ENDOCARDITIS. 

Synonyms. Valvulitis ; exudative endocarditis. 
Definition. An acute fibrinous inflammation of the serous mem- 
brane lining the cavity of the heart and particularly its valves, in 



DISEASES OF THE CIRCULATORY SYSTEM. 365 

severe cases the chordae tendineae being involved, resulting in changes 
in the valves or orifices of the heart, or both ; characterized by cough, 
dyspnoea, disturbed cardiac action, nausea, vomiting, and more or 
less marked febrile reaction. 

Acute endocarditis occurs in two distinct forms : plastic or simple 
exudative endocarditis ; ulcerous or diphtheritic endocarditis. 

Causes. Usually secondary to acute articular rheumatism (par- 
ticularly in young people), pleuritis, pneumonia, pericarditis, Bright's 
disease, scarlatina, influenza, and diphtheria. Rarely attacks of 
endocarditis are due to a gonorrhoea. The association of acute endo- 
carditis and chorea is frequent. 

While as yet no specific micro-organism has been discovered, the 
view is gaining, however, that it is a microbic affection. 

Pathological Anatomy. Inflammation of the endocardium is 
usually limited to the left side of the heart after birth, during fcetal 
life the reverse being the case. The inflammation is limited or espe- 
cially marked at the valvular portions of the endocardium, owing 
probably to the presence of fibrous tissue beneath the membrane in 
these situations, and to the strain which falls upon the valves during 
the performance of their functions. 

Hypercemia from congestion of the vessels beneath the membrane, 
with considerable swelling of the valvelets, the result of an exudation 
of lymph and serum beneath and on the free surface of the membrane 
covering the valves and chorda iendinece, resulting in the roughening 
of the surfaces and the agglutination of the mitral valves to each 
other, and of the aortic segments to the walls of the aorta, or the pro- 
liferation of the endocardial connective tissue, forming the nuclei 
of the so-called warty excrescences or vegetations, their size being 
increased by the deposition of fibrin from the blood on its passage 
through the orifices. 

These vegetations may be detached by friction, giving rise to emboli, 
which may be washed by the blood current to the left side of the 
brain, or into the kidneys and the spleen. 

In the ulcerative variety a process of softening takes place in the 
fibrinous deposits, leading to ulcerations and perforations. 

Symptoms. The affection is usually masked by the course of 
another disease until disturbances of the circulation direct attention 
to the heart. 

The onset is often by increase of temperature, pi'czcordial distress, 



366 PRACTICE OF MEDICINE. 

short cough, slight dyspnoea, more or less persistent vomiting ; increased 
cardiac action, often rapid and tumultuous, with throbbing carotids 
and noises in the ear. As the inflammation progresses, the cardiac 
action and pulse decline in frequency, with more or less congestion 
of the lungs and venous stasis. 

Auscultation. Shows a change in the character of the sounds 
or the development of murmurs at the various orifices, the character 
and points of distinction between which will be pointed out when 
discussing valvular diseases of the heart. 

Duration. Between one and three weeks. 

Diagnosis. Unless it is a rule of practice to always auscult the 
heart, many cases will pass unobserved or undetected. 

Pericarditis is distinguished from endocarditis by the character of 
the physical signs. In pericarditis the murmur or friction sound is 
heard with either cardiac sound, is near to the ear, and influenced by 
pressure of the stethoscope, besides being associated with more or 
less alteration in the size and shape of the cardiac dullness, and is 
not transmitted, while in endocarditis the murmur takes the place of 
or is associated with the cardiac sounds, and is transmitted to points 
beyond the praecordia, with the absence of change in size and form 
or increased dullness on percussion. 

If embolism occur, a new set of symptoms develop ; embolism of 
the kidneys causes sudden, deep-seated lumbar pain, with albumi- 
nuria and even haematuria'; embolism of the brain, sudden palsies and 
sudden disturbance of consciousness ; of the spleen, sharp pain and 
tenderness in the splenic region ; of the skin, petechial or purpuric 
spots. 

Prognosis. Acute endocarditis is not very dangerous to life, 
hence a favorable prognosis may be given ; regarding the ultimate 
results of valvular lesions, however, the prognosis is grave. 

Treatment. Absolute rest in bed. At the onset leeches or wet 
cups to the praecordium, followed by ice, or, what may be preferable 
to the patient, poultices. 

The excited circulation should be controlled by aconitum,veratrum 
viride, or digitalis, each of these drugs having their particular indi- 
cation. 

The free administration of such alkalies as ammonii carbonas, 
potassii acetas or carbonas, until the urine is decidedly alkaline, may 
prevent permanent changes in the valves or orifices. 



DISEASES OF THE CIRCULATORY SYSTEM. 367 

If alkalies fail and the inflammation shows a tendency to linger, 
good results are often obtained by a slight hydrargyrum impression. 

If signs of oppressed circulation appear, the hands becoming blue, 
the face and extremities cedematous, -with congestion of the lungs, 
the free use of ammonii carbonas, spiritus ammonii aromaticus , nitro- 
glycerinum, digitalis, strophanthus , hypodermic injections of strych- 
nines sulphas, and stimulants are indicated. No drug equals airopince 
sulphas in oedema of the lungs, no matter what the cause. The free 
use of ammonii carbonas will often prevent or break up heart clots. 
After the acute symptoms have subsided, more or less absorption of 
the exuded lymph has followed the free use of potassii iodidum. 
During the entire course of the affection the diet should be of the 
most nutritious but digestible character. 



MALIGNANT ENDOCARDITIS. 

Synonyms. Ulcerative endocarditis ; septic, mycotic, and diph- 
theritic endocarditis. 

Definition. An acute, septic inflammation of the lining mem- 
brane of the heart, with a strong tendency to ulceration ; characterized 
by depression o f the vital forces with more or less cardiac distress. 

Causes. The specific micro-organism has not yet been deter- 
mined. Frequently complicates pneumonia. Associated with ery- 
sipelas and septicaemia. Rarely associated with acute rheumatism. 
Cases have been reported associated with or following influenza. 
Gonorrhoea is a rare cause. 

Pathological Anatomy. The changes are those of acute en- 
docarditis up to the development of the thickening of the endocar- 
dium lining the valves, and the development of the vegetations. 
Instead of the poison spending its force and the chronic condition 
obtaining, a process of softening, ulceration, development of abscesses 
and perforation of leaflets follows, resulting in loss of structure, gen- 
eral septic infection, and the development of emboli, which lead to 
infarctions, with their results in either brain, kidney, spleen, eye, or 
skin. 

Symptoms. Vary greatly, but always associated with constitu- 
tional signs of sepsis — a typhoid state, such as headache, restlessness, 
varying delirium with coated, dry tongue, sordes on teeth and lips, 



368 PRACTICE OF MEDICINE. 

nausea, vomiting, loose or disordered stools, enlarged spleen, albumin 
in urine, and an irregular temperature record, varying from ioo° to 
104 F. or higher, associated with rigors and profuse sweati?ig. 

The cardiac action is rapid, irregular, and weak — a compressible 
pulse. 

In the notes of twelve cases observed in the Philadelphia Hospital 
are the following symptoms : attacks of prolonged dyspnoea with par- 
oxysms of intensity, or a slightly quickened respiration with parox- 
ysms of dyspncea occurring every few days in patients with hectic 
temperature record. In four cases the paroxysms occurred three 
times daily, with respirations under twenty-five between the parox- 
ysms, for three weeks preceding death. Usually the respirations are so 
oppressed that the recumbent position is impossible for long periods. 
Another frequent symptom is marked cyanosis, either transient or 
lasting for days before the end. 

A frequent symptom of ulcerative endocarditis is a peculiar fades, 
indicative of a sense of impending danger, great anxiety, or terror. 

If embolism occur, there are superadded symptoms varying with 
the organ affected. If the brain, rapidly developing palsies with 
disorder of consciousness ; if the kidneys, deep-seated lumbar pains 
with haematuria or disordered urinary flow ; if the spleen, pain and 
tenderness of the splenic region with increase of temperature record. 

Auscultation. The booming, muscular, first sound is superseded 
by a feeble, irregular cardiac pulsation. Generally, a murmur may 
be detected. 

Diagnosis. One of the most difficult in medicine. Remember- 
ing the diseases with which malignant endocarditis may occur, and 
particularly pneumonia or sepsis, and the dyspncea, the cyanosis, the 
facies, and the temperature record, it may be possible to detect the 
disease much more frequently than formerly. 

Prognosis. Unfavorable. Recovery the rarest termination. 

Treatment. Entirely symptomatic. Nutritious diet, quinince 
sulphas, ferrum, alcohol, strychnine sulphas, strophanthus, caffeina 
citratra, and digitalis. For the cyanosis, large, frequently repeated 
doses of nitro-glycerinwn. Local application seems only to distress 
the patient, unless it be an emplastrum belladonna. 



DISEASES OF THE CIRCULATORY SYSTEM. 369 

CHRONIC ENDOCARDITIS. 

Synonyms. Sclerotic endocarditis; interstitial endocarditis; 
chronic valvular disease. 

Definition. Alterations in the cardiac valves or orifices, render- 
ing the former incapable of properly closing the orifices, or causing 
the narrowed orifice to interrupt the blood current in its normal move- 
ment. 

The lesions are of two kinds : obstructive and regurgitant. 

An obstructive lesion, termed also stenosis, is a narrowing of the 
orifice, thereby obstructing the onward passage of the blood. 

A regurgitant lesion, termed also insufficiency , is such alteration in 
the valves as permits a portion of the blood to flow backward 
instead of onward, the true direction of the blood current. 

Varieties. I. Mitral regurgitation. II. Aortic regurgitation. III. 
Tricuspid regurgitation. IV. Pulmonary regurgitation. V. Mitral 
obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. 
VIII. Pulmonic obstruction. 

Causes. The great majority of cases are the result of an attack 
of acute endocarditis following rheumatism, chorea, or the infectious 
diseases. A chronic endocarditis from the onset may be caused by 
alcoholism, syphilis, gout, or excessive muscular labor. Chronic 
Bright's diseases are also exciting causes. 

Professor Da Costa has clearly established the development of 
aortic disease in early life by overwork and strain of the heart. 

In the elderly, chronic endocarditis is the result of atheromatous or 
fibroid changes. 

MITRAL REGURGITATION. 

This form of valvular disease is also termed mitral insufficiency, 
and is the most frequent variety of valvular heart disease. 

Pathological Anatomy. The most common conditions ob- 
served are more or less contraction and narrowing of the tongues of 
the valves, with irregular thickening and rigidity ; atheroma or calci- 
fication of the segments ; laceration of one or#more segments ; adhe- 
sion of one or more segments to the inner surface of the ventricle ; 
thickened and stiffened or rupture of the chordcs tendinea, and also 
contraction and hardening of the musculi papillares. 

As a result of the regurgitation or leakage of the blood back into 
32 



3T0 PRACTICE OF MEDICINE. 

the left auricle, there is a dilatation of the auricle, followed by slight 
cardiac hypertrophy. Ventricular hypertrophy occurs after a time 
from the increased number of the cardiac contractions. 

Symptoms. Insufficiency of the mitral valves soon leads to car- 
diac hypertrophy, to compensate for the diminished amount of blood 
sent onward by the ventricular systole. This condition causes 
quickened and strong pulse with some shortness of breath on severe 
exertion. When the " compensation ruptures," there occurs precor- 
dial distress, cough, dyspnoea ; feeble, soft, rapid, irregular pulse ; 
finally, from weakened cardiac action, may result pulmonary conges- 
tion, with cedematous limbs and general cyanosis, the abdominal 
cavity filled, liver congested, urine scanty and albuminous, the patient 
dying " drowned in his own fluid." 

Inspection. Cardiac impulse (apex-beat) displaced to the left 
and downward. In children and youths, bulging of the praecordia 
and increased Cardiac impulse. 

Palpation. Displaced cardiac impulse, early stage being forcible 
and diffused ; as compensation fails, impulse feeble or absent. 

Percussion. Transverse and vertical cardie dullness increased. 

Auscultation. Systolic blowing or churning murmur, audible in 
the mitral area, propagated to the apex, left axilla, and under the 
angle of the scapula, either occurring with or taking the place of the 
first sound of the heart, the second sound being markedly accen- 
tuated. 

Prognosis. So long as the compensating hypertrophy can be 
maintained, the prognosis is not unfavorable; when dilatation super- 
venes, however, the patient soon perishes, either from congestion of 
the lungs or dropsy and exhaustion. 

AORTIC REGURGITATION, 

Termed also aortic insufficiency, occurs next in frequency to mitral 
insufficiency. 

Pathological Anatomy. The valves or segments adhere to the 
walls of the aorta, or a segment is lacerated or may be perforated, or, 
more commonly, the segments are shrunken, deformed, and rigid, 
permitting the regurgitation of the blood. These deficiencies in the 
valves are usually associated with more or less dilatation of the 
orifices. 

The inability of the aortic valves to completely close the aortic 



DISEASES OF THE CIRCULATORY SYSTEM. 371 

orifice at the proper moment allows the blood that should go onward 
to flow back into the left ventricle, and the normal flow of blood from 
the left auricle continuing, causes overfilling of the ventricle, which 
results in a dilatation of its cavity, and the extra effort of the ventricle 
to empty itself results in hypertrophy of the walls. In no other con- 
dition does the dilatation and hypertrophy of the cardiac walls reach 
such a degree. The older writers named this enormous enlargement 
of the heart " cor bovinum." 

Symptoms. There are no characteristic symptoms so long as 
the insufficiency is compensated by just enough hypertrophy of the 
ventricular walls, but as the muscular growth increases, the symptoms 
are those of marked cardiac hypertrophy — to wit : forcible cardiac 
action, headache, tinnitus aurium, congestion of the face and eyes, 
with pulsating vessels, even small ones pulsating that before were not 
visible to the eye ; pulsations of the retinal vessels can be recognized 
with the ophthalmoscope ; the receding pulse, which is particularly 
characteristic — forcible impulse but rapidly declining, called "water- 
hammer " pulse and also the " Corrigan pulse." 

As soon as there is the slightest failure in the compensation, the 
cardiac action becomes excessive and distressing with palpitation, 
causing anxiety and fear upon the part of the patient. 

When "compensation ruptures," dyspnoea, increased on exertion, 
cough, cyanosis, hepatic enlargement, congestion of the kidneys, with 
scanty, albuminous urine, ascites, and dropsy develop either gradually 
or rapidly, calling for prompt medication. If mitral insufficiency is 
now superadded, general venous stasis and death rapidly occur. 

Precordial pain is usually present in aortic disease. It may be a 
sensation of constriction in the cardiac region, or sharp, shooting 
pains extending to the arms — anginoidal attacks. 

Inspection. Forcible cardiac impulse. 

Palpation. Strong, full cardiac impulse. 

Percussion. Cardiac dullness increasing transversely and verti- 
cally. 

Auscultation. First sound, forcible ; second sound, replaced or 
associated with a churning, rus/iing, or blowing murmur of low pitch, 
distinct at the second right costal cartilage, but most distinct at the 
junction of the sternum and the fourth left costal cartilage, trans- 
mitted downward toward and below the apex. 

Prognosis. The one valvular disease most likely to occasion 



372 PRACTICE OF MEDICINE. 

sudden death ; still, so long as the compensating hypertrophy remains 
intact, compatible with quite an active life. 

TRICUSPID REGURGITATION. 

Pathological Anatomy. This form of valvular insufficiency 
is either associated with right-sided cardiac dilatation from pulmonary 
obstruction, or is the result of mitral disease. 

The tricuspid orifice is dilated in the majority "of cases ; occasion- 
ally the segments of the valves are contracted or adherent to the 
ventricle. 

Symptoms. Venous stasis with its various consequences, and 
especially pulsation of the jugulars, synchronous with the cardiac 
movement, and, finally, general venous pulsation, especially of the 
liver, pulmonary congestion, engorgement of the kidneys, and dropsy. 
These symptoms are superadded to those of the affections with which 
tricuspid insufficiency is always associated. 

Inspection. Diffused, wavy, cardiac impulse ; jugular pulsation 
synchronous with the cardiac movement, uninfluenced by respiration, 
also more or less prominent hepatic pulsation. 

Palpation. The cardiac impulse extended, but feeble. 

Percussion. Dullness on percussion, extending to the right and 
below the sternum. 

Auscultation. The first sound is accompanied by a blowing 
murmur most intense at the junction of the fourth and fifth ribs with 
the sternum, distinct over the xiphoid appendix, becoming feeble or 
lost in the left axillary region ; often associated, however, with a 
mitral systolic murmur. 

PULMONIC REGURGITATION. 

Pathological Anatomy. Insufficiency of the pulmonary valves 
is of rare occurrence, but when present, the changes correspond more 
or less with those described for aortic regurgitation. 

Symptoms. Those of dilatation of the right side of the heart 
and consequent pulmonary congestion — to wit : dyspnoea, deficient 
aeration of the blood and cyanosis, distention of the superficial ves- 
sels, palpitation of the heart, precordial distress, sudden suffocative 
attacks, and dropsy. 

Percussion. The cardiac dullness extending to the right of the 
sternum. 



DISEASES OF THE CIRCULATORY SYSTEM. 373 

Auscultation. A loud, blowing murmur associated with the 
second sound of the heart, most distinct at the junction of the third 
left costal cartilage and the sternum. 

Prognosis. Death results, sooner or later, from dropsy and 
exhaustion. 

MITRAL OBSTRUCTION. 

Mitral obstruction or stenosis is not so frequent as regurgitation, 
and is very often associated with the latter. 

Pathological Anatomy. Mitral stenosis is caused by deposits 
around the orifice, the result of endocarditis, or else the segments of 
the valves are "glued together by their margins," leaving but a 
funnel-shaped opening, the so-called "buttonhole" mitral valve. 
Vegetations on the valves lead to more or less obstruction to the 
blood-current. 

Symptoms. Hypertrophy of the left auricle results from obstruc- 
tion at the mitral orifice, followed in time by dilatation, the symptoms 
of stenosis being unobservable until the " compensation ruptures," 
or until dilatation becomes excessive, when occur irregular, small, 
and feeble pulse, dyspncea, cough, bronchorrhcea the result of bronchial 
congestion ; dilatation of the right side of the heart, soon leading to 
general venous stasis, dropsy, and death. 

Inspection. Normal until auricular hypertrophy, when an undu- 
latory impulse is observed over the left auricle. 

Palpation. When cardiac dilatation occurs, a diffused, feeble, 
and irregular cardiac impulse is felt near the xiphoid appendix. 

Auscultation. First sound normal in character, but often irreg- 
ular in rhythm. The second sound normal. A blowing, sometimes 
rasping, sound is heard, immediately after the second sound of the 
Tieart ceases, and immediately before the first sound begins — a pre- 
systolic murmur, heard most distinctly in the mitral area, lessening in 
intensity toward the cardiac base. The cardiac sounds are all more 
or less enfeebled if cardiac dilatation occur. 

Prognosis. The prognosis is controlled by the duration of the 
hypertrophy. Under favorable circumstances, mitral stenosis is 
compatible with a long and rather active life. 

AORTIC OBSTRUCTION. 

Pathological Anatomy. Stenosis of the aortic orifice is caused 
by the projection of the valves inward, and their becoming rigid 



374 PRACTICE OF MEDICINE. 

and thickened, or atheromatous or calcareous, so that they cannot be 
pressed back by the blood, but remain constantly in the current of 
the circulation. Occasionally the valves are covered with fibrinous 
masses, the opening into the artery being thus more or less com- 
pletely closed, or the segments may be adherent by their lateral 
surfaces, leaving a central opening, which may be so contracted as to 
permit the passage of only the smallest probe. 

Aortic stenosis is nearly always a disease of advanced life, and is 
associated with the arterial changes of age. Aortic disease is not 
nearly so often of rheumatic origin as mitral diseases. 

Symptoms. Hypertrophy of the left ventricle rapidly super- 
venes upon aortic stenosis, and so long as the cardiac hypertrophy is 
just sufficient for compensation, there will be no subjective symptoms, 
many cases of stenosis being discovered when the individual is ex- 
amined for insurance or other reasons. The pulse is small, slow, and 
hard. When, however, the compensatory hypertrophy begins to fail, 
the supply of blood to the brain is insufficient in many cases, and 
pallor, with attacks of vertigo, syncope, or slight epileptiform seizures 
occur; finally, as dilatation of the left ventricle and incompetence 
of the mitral valve result, there occur pulmonary congestion, 
dyspnoea, and general venous stasis, the pulse soft and feeble. 

Palpation. Lowered cardiac impulse, strong in the early stage, 
feeble when dilatation occurs. 

Percussion. The cardiac dullness is increased vertically, the 
transverse dullness being but slightly increased. 

Auscultation. The first sound of the heart is replaced or asso- 
ciated with a harsh, raspitig sound, whistling at times, having its 
greatest intensity at the junction of the second right costal cartilage 
with the sternum, transmitted along the vessels ; the murmur may 
sometimes be heard a short distance from the patient. 

Usually, aortic stenosis is associated with more or less aortic regur- 
gitation, whence a double murmur occurs , having its greatest intensity 
at the base of the heart, the so-called to and- fro, or see-saw murmur. 

Prognosis. So long as compensation is maintained the condi- 
tion of the patient is comfortable, if a quiet life be followed. When 
the compensation is ruptured, the usual symptoms of dilatation, 
venous stasis, and dropsy soon ensue. 



DISEASES OF THE CIRCULATORY SYSTEM. 375 

TRICUSPID OBSTRUCTION. 

This condition is one of the rarest affections of the heart, and if it 
ever does occur with or following an attack of endocarditis, the 
anatomical changes are similar to those of mitral obstruction. This 
condition soon leads to auricular dilatation ; venous stasis rapidly 
supervenes, associated with venous pulsations similar to those de- 
scribed when speaking of tricuspid regurgitation. 

PULMONIC OBSTRUCTION. 

Pathological Anatomy. Always a congenital malady, the 
changes consisting in " constriction of the pulmonary artery, un- 
closed foramen ovale, unclosed ductus Botalli, stricture at the ductus 
Botalli, with hypertrophy of the right cavity and frequent association 
with tuberculosis of the lungs." 

Hypertrophy of the right ventricle may ensue, the walls becoming 
almost as thick as those upon the left side. 

Those in whom these congenital defects in the cardiac structure 
occur are otherwise weak, develop slowly, have flabby tissues, soft 
bones, and seem poorly nourished. 

Symptoms. The hypertrophy which often ensues may keep life 
apparently comfortable for some time, but sooner or later " compen- 
sation ruptures," when cough, dyspnoea, cyanosis, and death occur. 

Prognosis. The duration of these congenital affections is short, 
usually from a few days to a few months ; although several well- 
authenticated cases record a much longer duration. 

DIAGNOSIS OF VALVULAR DISEASES. 

In making a differential diagnosis between the various forms of 
valvular disease of the heart, strict attention must be paid to the 
points of greatest intensity at which the several murmurs are heard. 

A murmur occurring with or taking the place of the first sound of 
the heart — the ventricular systole — heard most distinctly at the apex, 
transmitted to the left axilla, and to the inferior angle of the scapula, 
signifies mitral regurgitation — a mitral systolic murmur. 

A murmur occurring with or taking the place of the first sound of 
the heart, with its point of greatest intensity at the xiphoid appendix, 
signifies regurgitation at the tricuspid orifice — a tricuspid systolic 
murmur. 



376 PRACTICE OF MEDICINE. 

A murmur heard with the first sound of the heart, high-pitched, 
rasping or grating in character, with its point of intensity greatest at 
the second right costal cartilage, signifies obstruction at the aortic 
orifice — an aortic systolic murmur. 

A murmur heard with the first sound of the heart, soft in character, 
with its point of intensity most distinct at the junction of the third 
left costal cartilage with the sternum, signifies obstruction at the pul- 
monic orifice — a pulmonic systolic murmur. 

A murmur occurring immediately after the second sound of the 
heart, and immediately before the beginning of the first sound of the 
heart, signifies obstruction at the mitral orifice — a presystolic mitral 
murmur. 

A murmur heard with or taking the place of the second sound of 
the heart, most distinct at the second costal cartilage, to the right of 
the sternum, and well transmitted toward the apex or below, signifies 
insufficiency or regurgitation at the aortic orifice — an aortic regurgi- 
tant or diastolic murmur. 

Although eight distinct valvular murmurs have been described as 
occurring in the heart, those on the right side are of rare occurrence, 
and hence of little clinical importance. 

If a murmur be heard with the first sound of the heart, it is almost 
certainly aortic obstructive or mitral regurgitant ; and if heard with 
the second sound, it is probably aortic regurgitant. A presystolic 
mitral murmur is also of comparatively rare occurrence, the force 
with which the blood passes from the left auricle into the left ventricle 
being, under ordinary circumstances, insufficient to excite sonorous 
vibrations. 

Functional or anceynic murmurs may be confounded with the va- 
rious forms of valvular disease of the heart. The chief points of dis- 
tinction between them are, that an anaemic murmur, which is always 
heard at the base of the heart, is always systolic in time, not trans- 
mitted away from the heart, and is soft in character, low in pitch, and 
of variable intensity, now being heard, now entirely absent. 

Treatment. There is no special plan of treatment for each form of 
valvular disease. Prof. J. M. Da Costa says : " I hold that the precise 
valve affected is not, with our present resources, the keynote to the 
treatment of valvular heart disease. We are to take as indications : 
I. The state of the heart-muscle and of the cavities. 2. The rhythm 
of the heart-action. 3. The condition of the arteries and veins and 



DISEASES OF THE CIRCULATORY SYSTEM. 377 

of the capillary system. 4. The probable length of existence of the 
malady and its likely cause. 5. The general health. 6. The second- 
ary results of the cardiac affection." 

A good rule in practice is that if the apex-beat is not displaced, the 
cardiac dullness is not increased to the right of the sternum, and dysp- 
noea is absent, medication is not indicated and even maybe injurious. 

The important point to bear in mind in the treatment of valvular 
disease of the heart is that it is associated either with cardiac hyper- 
trophy or dilatation, and the treatment, if any at all be required, is 
directed toward this secondary condition. If compensation be com- 
plete, attention to the condition of the bowels, kidneys, and digestion, 
with some general directions as to exercise, are all that is required. 

If the hypertrophy become excessive, it is best controlled by either 
aconitum, veralrum viride, or spiritus glonoini. 

If dilatation have occurred, the heart's action weak and feeble, the 
circulation impeded, and venous stasis has followed, digitalis, caffeines 
citrata, strophanthics, or sparteines sulphas, with more or less active 
purgation, is indicated. 

If fatty degeneration of the heart result, the indications are for car- 
diac rest, strychnines sulphas, stimulants, strophanthics, or spiritus 
glonoini, and attention to the excretions. 

If the cardiac rhythm is disturbed, add belladonna or lithii bromi- 
du??i to whatever other plan of treatment is being used. 

If the capillary circulation is weak, strophanthus and nitro-glycer- 
z/z^;/z(gIonoinum) act better than digitalis, which latter has the power 
of contracting the arterioles. 

Any of the secondary results of the valvular affection are to be 
treated according to the particular indications. 



CARDIAC HYPERTROPHY. 

Definition. An overgrowth or increase in the muscular tissue 
which forms the walls of the heart ; characterized by forcible impulse, 
over-fullness of the arteries, diminished blood in the veins, and accel- 
erated circulation. 

Causes. Obstruction to the outflow of blood, resulting from 
valvular disease of the heart ; emphysema ; Bright's disease ; arterio- 
fibrosis ; functional over-action ; excessive use of tobacco, tea, coffee, 
or excessive muscular action. 



378 PRACTICE OF MEDICINE. 

Varieties. I. Simple hypertrophy ■, or a simple increase in the 
thickness of the cardiac walls ; II. Eccentric hypertrophy , increase 
in the cardiac walls and dilatation of the cavities, causing a dilated 
hypertrophy ; III. Concentric hypertrophy, increase in the cardiac 
walls with decrease of the cavities, a very rare form. 

Pathological Anatomy. Hypertrophy of the heart is usually 
limited to the left side, the ventricles more commonly than the auri- 
cles, the latter dilating. 

The shape of the heart is altered by hypertrophy ; if the right ven- 
tricle, the heart is widened transversely and the apex blunted ; if the 
left ventricle, the heart is elongated and, as a rule, the cavity is 
dilated ; if both ventricles are hypertrophied, the heart has a globular 
shape. From increase in weight the heart'may sink lower during the 
recumbent position, thereby lessening the area of cardiac dullness, 
but during the sitting or upright posture it sinks lower in the chest 
and to the left, causing more or less prominence of the abdomen. 

The increase in the size of the organ is a true increase or hyper- 
trophy of the muscular tissue, and not a hyperplasia. The tissue is 
firmer and the color brighter and fresher than when the size of the 
organ is normal. 

The cor bovi?ium of the old writers is an enormous hypertrophy of 
the heart with dilatation of its cavities. 

Symptoms. Depend upon the amount of hypertrophy. The 
most common are increased and forcible cardiac action, the arteries 
becoming fuller, the veins less full, and the circulation accelerated ; pul- 
sating carotids and aorta, headache, often vertigo, frequent epistaxis, 
congestion of the face and eyes, tinnitus auriwn, dyspnoea on exertion, 
dry cough, restless nights, with more or less jerking of the limbs ; oc- 
casional praecordial pains shooting toward the left axilla ; full, firm, 
bounding pulse, and pulsations in the superficial arteries. 

A sphygmographic tracing shows the line of ascent vertical and 
abrupt, but the apex is rounded, and the line of descent is oblique, 
unless there is more or less insufficiency of the valves. 

Inspection. Often fullness or prominence of the prascordium, 
with distinct impulse. 

Palpation. The impulse is felt one or two intercostal spaces lower 
down and to the left, and is stronger and more or less diffused — the 
heaving impulse. 

Percussion. The area of cardiac dullness is increased vertically 



DISEASES OF THE CIRCULATORY SYSTEM. 379 

and transversely upon the left side of the sternum, unless the right 
ventricle is also hypertrophied, when the cardiac dullness is increased 
to the right of the sternum. 

Auscultation. If simple hypertrophy without any coexisting 
changes in the valves or orifices, the first sound has a loud and some- 
what metallic quality, the second sound being strongly accentuated. 

Sequelae. Cerebral hemorrhage ; miliary cerebral aneurisms ; 
dilatation of the heart ; fatty changes in the cardiac tissue. 

Diagnosis. Hypertrophy of the heart can scarcely be mistaken 
for any other disease if a careful study of the physical signs be made. 

Prognosis. When the result of valvular disease, the hyper- 
trophy is said to be compensatory. If the result of Bright's disease, 
emphysema of the lung, or if occurring late in life, or associated with 
atheromatous degeneration of the vessels, the prognosis is unfavorable. 
When the result of functional over-action in the strong and robust, a 
further enlargement can often be prevented by active and persistent 
treatment. 

Treatment. The indications are, if the hypertrophy be exces- 
sive, to lessen the force and number of the cardiac pulsations and to 
remove the cause whenever possible. 

The former indications are best met by the persistent use of tinctura 
aconilim small doses, Tr\j-ij (0.06-0.12 Cc), three times a day, or tinc- 
tura verairi viridis, li\j— ij (0.06-0.12 Cc), three times a day, and at 
the same time keeping the bowels, kidneys, and the skin acting freely. 
A certain amount of hypertrophy is beneficial in chronic valvular 
disease, and drugs should not be administered simply because a car- 
diac murmur is discovered on auscultation. 

The habits of the patient are to be corrected, all laborious or active 
exercise to be restricted, the patient to be in the recumbent posture 
several hours during the day if possible, the diet being restricted, 
avoiding all forms of stimulants, such as liquors, tobacco, tea, and 
coffee. 

Cases of cardiac hypertrophy associated with Bright's disease are 
often relieved by digitalis, the cardiac distress being secondary to the 
kidney disease, for which the digitalis is used. 

There is no doubt that in rare instances cardiac pain follows the 
use of digitalis, which is probably due to the firm and powerful car- 
diac contractions produced by digitalis ; such cases do better with 
caffeincB citrata or stropha7ithus. 



380 PRACTICE OF MEDICINE. 

Cases of cardiac hypertrophy associated with anaemia should, in 
addition to digitalis and rest, be placed upon a course oiferrum. 



DILATATION OF THE HEART. 

Definition. An increase in the size of one or more of the cavities 
of the heart, characterized by feebleness of the circulation, terminat- 
ing in venous stasis, cyanosis, oedema, and exhaustion. 

Causes. Over-exertion in those of feeble resisting powers, as 
youths or soldiers, as first pointed out by Prof. Da Costa; chronic 
valvular disease; emphysema; chronic bronchitis; gout; Bright's 
disease ; alcoholism ; syphilis. 

Varieties. I. Simple dilatation, the cavities being enlarged, the 
walls normal. II. Active dilatation, corresponding to eccentric 
hypertrophy ; the cavities being enlarged and the walls increased in 
thickness, the so-called " dilated hypertrophy." III. Passive dilata- 
tion, the cavities being enlarged and the walls thinned or stretched. 

Pathological Anatomy. The right side of the heart is far 
more frequently involved than the left side. The shape of the organ 
is altered, depending on the part affected. The weight of the organ 
is, as a rule, increased, as hypertrophy almost always accompanies or 
precedes dilatation. 

The muscular tissue is generally pale, mottled, and softened, and 
under the microscope presents evidences of degeneration. The orifices 
also participate, and especially the auriculo-ventricular orifice, result- 
ing in the valves becoming incompetent to close the orifices, and this 
latter effect is added to by the removal of the basis of the papillary 
muscles a greater distance from the orifice, in consequence of the 
extension of the wall. 

When the auricles dilate, the large venous trunks opening into them 
unprotected by valves commonly participate in the dilatation, and 
may become greatly enlarged. 

The passive congestion of the organs that follows the feeble circu- 
lation produces changes in their structure. 

Symptoms. Those associated with enfeebled circulation — to wit : 
Feeble pulse, veins distended, arteries emptied ; headache, aggravated 
by the upright position ; attacks of syncope, cough, with any of the fol- 
lowing phenomena of venous congestion; of the lungs, dyspnoea; 
liver, jaundice ; stomach, dyspepsia; intestines, constipation; kid- 
neys, scanty, often albuminous, urine ; brain, dullness of the mind 



DISEASES OF THE CIRCULATORY SYSTEM. 381 

and vertigo, often relieved by a copious epistaxis ; and, finally, dropsy, 
beginning in the lowerextremities, the patient dying from exhaustion. 

Great relief often temporarily follows any of the above symptoms 
under treatment ; sooner or later, however, the venous stasis produces 
the final symptoms noted. 

Inspection. Veins of the surface distended and enlarged ; in- 
distinct cardiac impulse, often diffused and wavy ; if associated with 
tricuspid insufficiency, there is pulsation of the jugular. 

Palpation. Feeble and irregular fluttering, but heaving impulse. 

Percussion. Cardiac dullness extended transversely, and espe- 
cially increased on the right side. 

Auscultation. If no valvular lesion accompany the dilatation, 
the cardiac sounds are weaker than normal, the first sounds having a 
sharper quality than normal ; if accompanied by valvular lesions, 
cardiac murmurs are present. 

Diagnosis. Hypertrophy of the heart shows increased cardiac 
dullness, and is a disease of powerful cardiac action, while dilatation 
is an affection of feeble action associated with dropsy. 

Pericardial effusion has many points of resemblance to cardiac 
dilatation, but it begins suddenly, associated with some acute malady, 
and while the heart sounds are indistinct or feeble at the apex, they 
both have their normal qualities at the cardiac base, while dilatation 
of the heart has a chronic history, results in general venous stasis, the 
cardiac sounds being of the same intensity over the entire prascordium. 

Prognosis. Unfavorable, death resulting from gradual exhaus- 
tion, or suddenly by cardiac paralysis if there be some undue excite- 
ment. With careful living life may be prolonged for years. 

Treatment. Dilatation of the heart is incurable. In all cases 
there are two important indications : The first to maintain the general 
nutrition of the patient, and the second to control or prevent all 
irregular or violent cardiac action. The first is accomplished by a 
generous diet, moderate exercise, with bitters to increase the appetite 
and ferrum to improve the blood, and, in a majority of cases, the 
more or less free use of a good red wine. 

The second indication is met by the observance of strict rules in 
regard to exercise and such heart tonics as digitalis in powder, tinc- 
ture, or infusion, or a combination like the following : 

R. Tincturce nucis vomicae, . . . . f,^ss 15. Cc. 

Tincturae digitalis, f5ss 15. Cc. M. 

Sig. — Fifteen to twenty drops after meals, in water. 



382 PRACTICE OF MEDICINE. 

Drs. Hare and Coplin have demonstrated by careful research that 
the prolonged use of digitalis actually increased the development of 
the normal heart muscle. 

Strychnines sulphas, gr. ■£% (0.0025 Gm.), three times daily, is a 
valuable cardiac tonic ; the same may be said of caffeines citrata, gr. 
j-iij (0.06-0.2 Gm.), three or fcnir times daily. Sparteines sulphas is a 
powerful cardiac tonic, particularly of service in the dilating heart of 
Blight's disease. The faictura strophanthus, alone or in combina- 
tion with digitalis, is valuable. Extractum convallariae fluidum is 
not always reliable. Morphincz sulphas in small doses, particularly 
when compensation is failing and the dropsy becomes great and 
is associated with marked cyanosis, hypodermicalry, as suggested by 
Prof. Bartholow, " often acts like magic in restoring the circulation." 

The following pill is often of great advantage : 

R. Ferri reduct. , gr. j-ij .065- 13 Gm. 

Quininse sulph., gr. j — ij .065-.13 Gm. 

Pulv. digitalis, gr. j .065 Gm. 

Morphinae sulph. , g r - 2? •°° 2 5 Gm. M. 

SiG. — Three times a day. 

An excellent combination is the following : 

R . Tinct. digitalis, ......... f^iss 6. Cc. 

Tinct. cacti grandiflor., . . . . f^j 30. Cc. • 

Caffeinae citrata, ....... ^j 4. Gm. 

Tinct. card, comp., .... adf^iv ad 120. Cc. M. 

SiG. — Teaspoonful, diluted, three or four times daily. 

The bowels, skin, and kidneys should be kept in action, using, if 
needed, purgatives, diaphoretics, and diuretics. The following combi- 
nation, suggested by Dr. J. M. Anders, is satisfactory in many in- 
stances : 

R. Caffeinae citrata, ^j 4. Gm. 

Strychninae sulph., gr. y$ .022 Gm. 

Sparteinae sulph. , gr. ij .13 Gm. M. 

Ft. capsulae No. xij. 

SiG. — One every three or four hours. 

Or the following excellent diuretic pill : 

R. Pulv. scillac gr. xxx 2. Gm. 

Pulv. digitalis, gr. xxx 2. Gm. 

Caffeine citrata, gr. xxx 2. Gm. 

Hydrarg. chlor. mitis, gr. v .3 Gm. M. 

Ft. pilulae No. xxx. 

SiG. — One three or four times daily. 



DISEASES OF THE CIRCULATORY SYSTEM. 383 

If pulmonary congestion develop, dry cups, digitalis, cajfeina, atro- 
phia, and stimulants. 

For cardiac asthma, dry cups, morphines sulphas, hypodermically, 
or spiritus cztheris compositus (Hoffman's Anodyne). 

For hepatic congestion, blue mass or podophyllin. 

For dropsy, dry cups over the kidney digitalis with potassii acetas, 
with scoparius and juniperus, and pulv.ja lap ce comp., 5j-ij (4-8 Gm.), 
in water, before breakfast. 

If the dropsy is uninfluenced by the above means, success will 
follow the use of hydrargyri chloridi milis, gr. iij (0.2 Gm.), guarded 
with pidves opii, gr. ^ (0.005 Gm.), three or four times a day. 

The treatment of cardiac dilatation and cardiac failure by baths 
and systematic exercise has excited much interest and discussion re- 
cently, with the result of its indorsement in proper cases. Exercise is 
employed in one of three plans or, rarely, a combination of these 
plans : (i) passive exercise and massage (Swedish or Ling plan) ; (2) 
movements with limited resistance (Schott plan, but really a modifi- 
cation of the Swedish); (3) method of climbing (Oertel). The baths 
to be those of the Nauheim (saline) natural waters. A number of 
American and English clinicians report good results with artificial 
Nauheim baths. This system of cardiac treatment is associated with 
regulated diet and the use of some cardiac tonics, and business rest. 



ACUTE MYOCARDITIS. 

Synonyms. Carditis ; abscess of the heart. 

Definition. An inflammation of the muscular tissue of the heart, 
by extension from an inflamed pericardium or endocardium, or sec- 
ondary to pyaemia; characterized by pain, feeble circulation, symp- 
toms of blood-poisoning and collapse. 

Causes. The result of endocarditis or pericarditis ; pyaemia ; 
typhoid fever; emboli of the coronary arteries. 

Pathological Anatomy. Discoloration and softening of the 
cardiac substance and the infiltration of a sero-sanguineous fluid, 
fibrinous exudation and pus, leading to the formation of abscesses in 
the muscular structure of the heart. 

The disease leads to the formation of either a cardiac aneurism or 



384 PRACTICE OF MEDICINE. 

to rupture of the walls of the heart. If recovery occur, cicatrices or 
depressed scars may mark the site of a former abscess. 

Symptoms. The clinical evidences of inflammation of the car- 
diac muscles are very obscure. If, during the course of one of the 
maladies mentioned, there are developed precordial pain, irregular 
and feeble cardiac action, cardiac dyspnoea, pyrexia of a low type, 
with symptoms of blood-poisoning and a tendency to collapse, or the 
symptoms of the so-called typhoid stale, myocarditis may be suspected. 

Diagnosis. The existence of myocarditis can scarcely ever be 
anything but a presumption, the signs being all negative rather than 
positive. If during the course of rheumatism, pyaemia, puerperal 
fever, typhoid fever, pericarditis, or endocarditis, symptoms of cardiac 
failure appear suddenly, associated with signs of blood-poisoning and 
collapse, inflammation of the cardiac muscle may be suspected. 

Prognosis. The course of acute myocarditis is very rapid, death 
being the usual termination in from three to five days. Chronic 
myocarditis pursues a very latent course. 

Treatment. Largely symptomatic. Perfect rest of mind, gen- 
erous diet, free stimulation, and the administration of quinince sul- 
phas, ferrui7i, and spiritus cEtheris nitrosi — a nitrite. 



CHRONIC MYOCARDITIS. 

Synonyms. Fibroid heart ; chronic interstitial myocarditis ; 
fibrous myocarditis ; chronic carditis ; cardio-sclerosis. 

Definition. A slowly developing hyperplasia of the interstitial 
connective tissue of the heart, leading to induration of its substance ; 
characterized by shortness of breath on slight exertion, attacks of 
tachycardia, prsecordial pain, disordered circulation, and vertigo. 
It is proper to state that many cases present no symptoms whatever. 

"Causes. The most frequent cause is sclerosis of the coronary 
arteries, leading to imperfect blood supply to the cardiac muscles. 
Among other frequent causes are diseases of the kidneys, alcohol- 
ism, excessive use of tobacco, syphilis, secondary to pericarditis, en- 
docarditis, and acute myocarditis. 

There is, undoubtedly, often an inherited predisposition to fibroid 
changes in the vessels, in which cases the causes named would act 
as exciting causes. 



DISEASES OF THE CIRCULATORY SYSTEM. 385 

It is a disease of the aged, save in those instances resulting from 
hereditary predisposition or from excesses. The old saying, " A man 
is as old as his arteries," is applicable to this disease. 

Pathological Anatomy. The heart is enlarged and dilated. 
The morbid changes may be diffused, or limited to the walls of the 
left ventricle, the papillary muscles, and the septum. There is always 
more or less atheromatous deposit or changes in the aorta. All cases 
show atheroma in one, more, or all of the coronary arteries. Com- 
plete closure of one coronary artery, if produced suddenly, is usually 
fatal. 

On section, the cardiac wall cuts with a distinct resistance. The 
changes in the heart wall are an " overgrowth of the interfibrillar con- 
nective tissue, with development of fibrous tissue. These changes 
may be uniformly distributed through the substance of the heart when 
some intoxication, as by alcohol, or some general disturbance of the 
cardiac nutrition, has led to the myocardial disease ; or they may be 
seen in circumscribed areas when embolic or thrombotic occlusion of 
branches of the coronary arteries has occasioned anaemic infarction 
and subsequent sclerosis. In either case the microscope reveals 
masses of wavy fibrous tissue between the muscular bundles, and 
often slow degeneration or atrophy of the fibres themselves " (Pepper). 

The terminal branches of the coronary arteries are narrowed and 
sclerotic to the point of obliteration, particularly in cases resulting 
from syphilis. 

"Aneurism of the heart is commonly due to localized cardio- 
sclerosis. The inelastic fibrous tissue gradually gives way before the 
intracardial pressure, and saccular dilatation results " (Pepper). 

Atheromatous changes are often found in other than the coronary 
vessels, particularly the aorta. 

Various degenerative changes occur in other organs, the result of 
disturbed circulatory action. 

Symptoms. The great majority of patients having chronic myo- 
carditis present no symptoms until an extra cardiac effort is called 
for. 

An early symptom is breathlessness on slight exertion, with either 
cardiac palpitation or a feeble, irregular pulse. Vertigo is frequent 
and distressing, increased by indigestion and costive bowels. An- 
ginal attacks (cardiac pain) or a sensation of constriction or pressure 
over the praecordium are frequent, often following some exertion or an 
33 



386 PRACTICE OF MEDICINE. 

attack of indigestion. The pulse-rate is often decreased in frequency 
in cases which present no other symptom. 

A frequent symptom is syncope, coming without warning or after 
sudden exertion, the result of sudden failure of the cerebral circulation. 

Among other periodical symptoms are cardiac asthma, pseudo- 
apoplectic attacks, and hepatic, gastric and nephritic disorders. 

As the fibroid changes progress, there develop progressive weak- 
ness, dyspnoea, insomnia, disordered digestion, and cerebral weak- 
ness, often showing itself as mania, delusional attacks, or dementia. 

Percussion. Increased praecordial dullness is usually present, 
due to the dilated hypertrophy. 

Auscultation. The first sound of the heart is valvular in char- 
acter, the booming or muscular quality having disappeared. Mur- 
murs are very frequent, the result of valvular disease. A very 
characteristic condition is the irregularity in rhythm and in force, one 
contraction being fairly forcible, another weak or feeble, and so on. 

Diagnosis. A proper appreciation of chronic myocarditis is one 
of the most important questions in clinical medicine. The term 
" Heart Failure" is the opprobrium of the profession, and yet chronic 
myocarditis is one of the great causes of cardiac failure during the 
prevalence of some over-exertion or in acute pneumonia, typhoid 
fever, and other like diseases. 

The points of value in arriving at a diagnosis are : a careful study 
of the first sound of the heart at the apex ; the character of murmurs 
if present, the condition of the arteries, the dyspnoea, the feeble, 
irregular pulse in patients past fifty years, and the occurrence of 
anginal attacks after exertion or mental worry. 

Prognosis. This is controlled by the habits of the patient. The 
disease is incurable, but life may be fairly comfortable for many years 
if care be exercised. 

Treatment. No remedy can remove the fibroid change. The 
indications are to promote the patient's nutrition, hold in check the 
progress of the fibrosis, and meet or prevent the symptoms as they 
arise. Constipation is often a troublesome symptom, and calls for 
such drugs as aloes or cascarce sagrada. 

For the general condition, ferrum, arsenicum, and the hypophos- 
p kites. 

For the breathlessness, spiritus glonoini (nitroglycerin, one per 
cent.), or spiritus cetheris nilrosi, or spiritus ammonia aromaticus. 



DISEASES OF THE CIRCULATORY SYSTEM. 387 

For cardiac palpitation, potassii bromidum, lithii bromidum, or 
spiritus ammonia aromaticus. 

For cardiac weakness, strychnines sulphas, gr. -fa (0.0025 Gm.), three 
or four times a day, and if the pulse is frequent, tinctura digitalis, 
tt^x-xx (0.6-1.2 Cc), three times daily, or caffeines citrata, gr. iij 
(0.2 Gm.), after meals ; maintaining the recumbent position and re- 
moving all unfavorable associate symptoms, as constipation, scanty 
urine, and dyspepsia with flatulence. 

For the anginal attacks, hypodermic injections of morphines sul- 
phas, gr. y%-% (0.008-0.016 Gm.), or chlorodyne, ff\,x-xx (0.6-1.2 Cc), 
repeated as needed. 

For the syncopal attacks, the patient should be placed in bed and 
stimulants administered, often used by the hypodermic method, with 
mustard over the praecordium, and TTLJ-ij (0.06-0.12 Cc.) spiritus 
glonoini every couple of hours. 

An excellent combination for breathlessness, vertigo, and chest 
pains is : 

R. Lithii brotnidi, . ^vss 22. Gm. 

Spiriti glonoini, W\, xv j *• Cc. 

Liq. potassii citratis, . . q. s. ad f^viij ad 240. Cc. M. 

SiG. — Tablespoonful four times daily, diluted. 

The patient must lead a quiet life, refrain from mental worry, phy- 
sical over-exertion, and eschew tobacco and malt liquors. The diet 
must be plain and simple, with but little tea or coffee. In the elderly, 
a small amount of good whisky once or twice a day is valuable. 



FATTY HEART. 

Synonyms. Fatty degeneration of the heart ; chronic myo- 
carditis. 

Definition. A change in the muscular fibres of the heart, in 
which the transverse strise are replaced by granules and globules 
of fat; characterized by feeble cardiac action, venous stasis, and 
dyspnoea. 

Causes. Impaired nutrition in the elderly ; prolonged anaemia ; 
chronic gout ; alcoholism ; phosphorus poisoning ; cancer ; tubercu- 
losis and scrofula ; diseases of the coronary arteries. 

Pathological Anatomy. The distinction must be made be- 



388 PRACTICE OF MEDICINE. 

tween a deposit of fatty tissue upon or around the heart, and the 
degeneration of its muscular tissue. 

The fatty metamorphosis may affect the whole organ, or the entire 
ventricular walls, or be limited to portions of them. If the degenera- 
tion be marked, the color is yellowish, the tissues soft and easily torn, 
and to the touch have a greasy feeling, oil being yielded on pressure. 

The microscopic changes are characteristic. The striae of the 
muscle are easily rendered indistinct by fat and oil globules, grad- 
ually becoming more and more obscured, and finally disappearing 
altogether, the fibres being replaced by fat granules. 

Symptoms. Those of weak heart, anaemia of organs, and 
venous stasis — to wit: feeble, iwegular, but slow cardiac action /com- 
pressible pulse, prcecordial distress, often aggravated by attacks of 
angina pectoris ; dyspnoea, aggravated on exertion, with anaemia of 
the various organs from the feeble propulsive power; if of brain, 
vertigo, swooning, or pseudo-epileptic attacks, especially marked on 
suddenly rising from a recumbent position ; if of lungs, dry, hacking 
cough ; if of gastro-intestinal tract, dyspepsia and constipation ; if of 
kidneys, scanty urine, at times albuminous, and finally dropsy, begin- 
ning in the lower extremities. 

A formidable symptom, causing much inconvenience as well as 
alarm to the patient, is what he will term his constant " sighing," the 
Cheyne-Stokes breathing — "A pause in the breathing, a complete 
suspension of the respiratory acts for a period of time (during which 
breathing might occur several times in the normal manner), then the 
resumption of respiration very feebly and slowly, and a gradual and 
progressive increase in the number and depth of respirations until 
the maximum is reached, and then again a gradual and progressive 
diminution in the same order, in the number and depth of the res- 
pirations, until another pause occurs " — the " oscillating respiration." 

Concomitant symptoms are atheromatous changes in the vessels, 
and the arcus senilis. 

Palpation. Weak cardiac impulse. 

Percussion. Not markedly changed unless preceded by enlarge- 
ment of the heart. 

Auscultation. First sound feeble, toneless, almost inaudible, 
the second sound being normal, unless changes in the valves are 
present. 

Diagnosis. Feeble cardiac sounds, with slow pulse, attacks of 



DISEASES OF THE CIRCULATORY SYSTEM. 389 

cardiac asthma or Cheyne-Stokes breathing, with evidences of arcus 
senilis, make the diagnosis very certain. The question of fibroid 
heart must always be considered. 

Prognosis. Incurable, the affections pursuing a more or less 
chronic course. Life may be prolonged at times by treatment, but 
death finally results from exhaustion, or suddenly from cardiac 
paralysis or rupture of the heart. 

Treatment. Incurable, there being no plan of treatment that 
can restore the degenerated muscular fibre. Generous diet, very 
moderate exercise, stimulants, oleum morrhucs, and the " triple 
elixir " — elixir ferri, quinines, et strychnines, or the hypophosphiles. 

All the excreting organs must be kept active, so as to relieve the 
crippled heart as much as possible. 

To sustain the cardiac action, strychnines sulphas, gr. 3V-4V (0.002- 
0.0015 Gm.), three or four times daily, is most valuable. Other drugs 
are caffeines citrata, sparteines sulphas, or tinctura nucis vomiccs. 
Digitalis is contra-indicated in advanced cases. 

For syncopal attacks, nitro-glycerinum {spiritus glonoini), spiritus 
atheris nitrosi, spiritus ammonice aromaticus, or hypodermic injec- 
tions of estheris, cajnphora, or spiritus frumenti. 

The recumbent position for hours each day is a valuable means 
of resting a crippled heart. 



PALPITATION OF THE HEART. 

Synonym. Irritable heart. 

Definition. A functional disturbance of the heart ; characterized 
by increasing frequency of its movements and more or less irregu- 
larity of the rhythm, with a strong tendency toward hypertrophy. 

Causes. Over-exertion, " the heart-strain " of Da Costa ; dyspep- 
sia ; uterine diseases ; excesses in tea, coffee, tobacco, alcohol, or 
venery ; moral and emotional causes, grief, anxiety, and fear. 

Symptoms. Usually palpitation of the heart has a sudden onset 
after some one of the causes mentioned, with precordial oppression 
or pain ; rapid, tumultuous beating, the impulse being visible through 
the patient's clothing ; dyspnoea, anxiety, and a sense of choking or 
fullness in the throat, the recumbent position being impossible; vertigo, 
faintness, flashes of light, the pulse full and strong or feeble, the face 



390 PRACTICE OF MEDICINE. 

flushed or ft ale, the patient having a feeling of anxiety with a sense 
of impending danger and a fear of sudden death. These attacks are 
paroxysmal, lasting from a few moments to several hours, or a day, 
the patient often voiding a large quantity of limpid urine after the 
paroxysm has subsided, when there is a strong tendency to sleep. 

Diagnosis. Irritability of the heart is differentiated from the 
various forms of cardiac disease by the absence of all the physical 
signs mentioned as occurring in those conditions. 

Prognosis. If early and properly treated, favorable. 

Treatment. The first point in the treatment of irritability of the 
heart is to remove the cause ; the next, to prevent the recurrence of 
the attacks of palpitation. 

The majority of cases do well after a few doses of either spiritus 
Getheris cojnposiius (Hoffman's anodyne) or spiritus ammonii aromati- 
cus, or a combination of digitalis and belladonna. Permanent relief is 
often afforded by a combination of potassii bromidum and veratrum 
viride. Trional, gr. x-xv (0.6-1 Gm.), three times daily, is often use- 
ful. If the patient be anaemic, excellent results follow the prolonged 
use of the elixir ferri, quinines, et strychnine?. Locally, emplastrum 
belladonncE to the praecordium affords relief. The acute attack is 
often wonderfully benefited by ice over the praecordium. 



TACHYCARDIA. 

Synonyms. Rapid heart ; quick heart ; paroxysmal rapid heart. 

Definition. Paroxysmal rapid cardiac action, minus or with sub- 
jective symptoms, the result of excessive cardiac rapidity. 

Causes. Tachycardia is one of the " crises " of cerebral or spinal 
diseases. Menopause. Neuritis of the pneumogastric nerve ; chronic 
myocarditis ; neurasthenia ; chronic gastritis ; excessive use of to- 
bacco (?) ; a variety of petit mal (?). 

Pathological Anatomy. No characteristic lesions. There 
may be paralysis of the inhibitory fibers of the vagus, an irritation of 
the accelerators of the sympathetic, or reflex action from some lesion 
in the cardiac wall or elsewhere. 

Symptoms. The paroxysm is sudden in its onset, with or 
without " warnings " — if these latter, they are in the shape of vertigo, 
ringing in the ears, and a sense of impending danger. The cardiac 



DISEASES OF THE CIRCULATORY SYSTEM. 391 

action is increased to 150, 175, 200, rarely 250 beats per minute. The 
pulse is small, weak, easily compressible, and often irregular, with 
carotid pulsation (which indicates the emptiness and low tension of 
the artery, as in aortic regurgitation). The respiration is slightly 
increased; rarely there is dyspnoea. The surface is at first pale, but 
soon becomes flushed. The expression is anxious and denotes suffer- 
ing. There is a feeling of precordial constriction, with more or less 
smothering. Rarely, there are no subjective symptoms. . 

The duration is from a few minutes to hours, or days. The attack 
usually ceases during sleep, but if it does not, the rapidity of the pulse 
continues during the disturbed sleep. 

Auscultation. The first sound is clear and ringing, but not 
strong and booming. The second sound is weak and lacks the val- 
vular quality of the normal. A murmur is often heard at the apex. 

Diagnosis. The differentiation between tachycardia and palpi- 
tation is to be made, as also the rapid heart of valvular disease and 
of irritable heart. The chief point is that in tachycardia the attack 
is paroxysmal, and the number of pulsations exceeds the rapid heart 
of other conditions. 

Prognosis. It is often an unfavorable symptom of some central 
lesion. If it develop in patients suffering from chronic myocarditis 
or atheroma of vessels, the fatal result may be sudden. 

Treatment. For the paroxysm, the application of ice to the prae- 
cordium, conjoined with a hypodermic injection of morphines sulphas, 
gr. ]/e (0.011 Gm.), and atropines sulphas, gr. T ^ u (0.00065 Gm.), and 
rest in bed. A few large doses of digitalis should always be tried. 
Tinciura belladonna, potassii broinidum, lithii bro7nidu?n, strontii 
bromidum, or camphorcs monobromas are often valuable ; remember- 
ing that which answers in one case or attack may be useless in 
another. Trional, gr. xxx (2 Gm.), seems to rapidly control a 
paroxysm. An ice bag over the prsecordium has cut short an attack. 

The arrest of attacks of tachycardia is reported from compression 
of the vagus in the neck. Nothnagel reports the case of a patient 
who could cut short an attack by a full and deep inspiration. 

Rosenfeld succeeded in cutting short an attack in four cases by 
having " the patient squeeze his own arms and elbows into his sides, 
and at the same time forcibly compress his abdomen." 

After the paroxysm , nutritious diet, avoidance of alcohol, tobacco, tea, 
and coffee, and a course of arsenicum, strychnina, or potassii iodidum. 



392 PRACTICE OF MEDICINE. 



BRADYCARDIA. 



Synonym. Brachycardia. 

Definition. A paroxysmal or permanent slowness in the cardiac 
action. It is agreed that bradycardia begins with a pulse reduced to 
at least forty beats per minute. 

Causes. Often associated with organic nervous diseases. It is a 
symptom of such cardiac diseases as fibroid and fatty heart and 
atheroma of the coronary arteries. 

It frequently occurs during convalescence from infectious diseases, 
such as diphtheria, pneumonia, typhoid fever, erysipelas, and rheu- 
matism ; uraemia, lead-poisoning, anaemia, and chronic alcoholism 
are often causes. Balfour says : " Many, if not most, of the sufferers 
from bradycardia are epileptics." 

Symptoms. Slow action of the heart is the chief symptom, 
varying from 40, 30, 20, to 10 or 8 beats per minute. The pulse is 
weak, small, and slow. As results of the slow cardiac action are 
vertigo, noises in the ears, syncopal attacks, and rarely convulsions. 
The onset may be either sudden or follow " warnings." 

Auscultation. The first sound is soft and feeble, and often the 
second sound is not heard. 

As a rule, with reduction in the number of contractions is an in- 
crease in their force, and this not obtaining in bradycardia determines 
its central origin. 

Diagnosis. A feeble cardiac contraction, with less than forty 
beats per minute, determines the diagnosis. 

Prognosis. Sudden death a very frequent termination. The 
cause controls the prognosis. 

Treatment. So long as the slow cardiac pulsations are sufficient 
to supply the requirements of the economy, medication is not 
needed; when, however, the reverse obtains, resort to rest in the re- 
cumbent position, heat to the praecordium, and the use of such reme- 
dies as atropines sulphas, caffeines citrata, strychnines sulphas, spiritus 
glonoini, or spiritus ammonia aromaticus. Often the emergency is 
so great as to call for the hypodermic use of the selected drug. 

Digitalis is contra-indicated. Between the paroxysms, such reme- 
dies as improve the general health and prevent the progress of the 
central or exciting cause. 



DISEASES OF THE CIRCULATORY SYSTEM. 393 



ARRHYTHMIA. 

Synonyms. Arrhythmia cordis ; irregularity of the pulse. 

Definition. A lack of cardiac rhythm, or irregularity in the car- 
diac pulsations. It is a symptom rather than a disease. 

Causes. Valvular diseases ; myocardial diseases ; cardiac dilated 
hypertrophy ; atheroma of coronary arteries and aorta ; excessive use 
of tobacco, tea, or coffee ; flatulent dyspepsia. Neurasthenia, hysteria, 
and melancholia. 

Symptoms. An irregularity in cardiac action, either in the 
rhythm or the regularity of the force of the beats, or an intermission 
in the cardiac contractions. 

The sphygmograph gives the exact condition of the cardiac pulsa- 
tions and should always be used in cardiac diseases. 

Other symptoms that may be present are due to the condition pro- 
ducing the arrhythmia. 

Diagnosis. An examination of the pulse, auscultation of the 
heart, and the use of the sphygmograph determine the arrhythmia. 

Prognosis. Depends upon the cause. In functional cases favor- 
able, in organic cases unfavorable. 

Treatment. Rest of mind and body, regulated diet, and atten- 
tion to the secretions. 

Tinctura nucis vomica, strychnines sulphas, and digitalis are each 
useful. In functional cases the bromides are valuable. 



ANGINA PECTORIS. 

Synonyms. Neuralgia of the heart ; breast-pang. 

Definition. Paroxysms in which there occur sharp cardiac pains, 
extending usually into the left shoulder and down the left arm, ac- 
companied by a feeling of constriction of the thorax and a strong 
fear of impending death. 

Causes. Often hereditary ; associated with chronic cardiac 
changes, disease of the coronary arteries or calcification of the 
valves ; the excessive use of tobacco (?) ; syphilis ; according to Trous- 
seau, it is a form of masked epilepsy, and may alternate with true 
epileptic attacks. Often associated with hysteria (?). 



394 PRACTICE OF MEDICINE. 

Pathological Anatomy. A disease of the arteries, ossification 
and occasionally obliteration of the cardiac arteries, producing car- 
diac ischaemia. 

"The pathological changes which stand in a causative relation to 
the attacks are those of the cardiac plexus of the phrenic and of the 
pneumogastric nerves. Pressure of enlarged lymphatics, inflamma- 
tion of parts of the cardiac plexus, with changes in the coronary 
arteries, seem to be most constant." 

Symptoms. A paroxysmal affection, the attacks occurring irreg- 
ularly ; in the interval entire absence of symptoms, or the symptoms 
of the organic disease causing the paroxysms. 

" The patient suddenly sits up in his bed ; with a cry of horror in- 
dicates the sense of pain at the praecordium. The pain is of great 
intensity, but is of a cold and sickening character ; the chest is fixed, 
the breathing quickened, and the hand placed over the praecordium 
finds that the heart's action is slight and enfeebled. The face wears 
a look of horror, pale and slightly leadened ; a cold sweat breaks out 
upon the forehead ; worse than the pain is the feeling of fearful sick- 
ness and depression. The poor patient gasps, 'I shall die! Ishall 
die ! ' and sometimes his short but concentrated sufferings in a few 
moments end in-death " (Sansom). The attack ends suddenly with 
vomiting, or great flow of urine. 

The unpleasant sensations of these patients during an attack, and 
the nervous disorder associated with it, slowly bring about a mental 
change. They are depressed and gloomy, sometimes suicidal, and 
often develop epilepsy. 

Attacks of angina in nervous women and children, the hysterical 
or pseudo-anginal attacks, come on gradually with distention of the 
abdomen, eructations of gases, excessive restlessness, flushed face, 
irritable pulse, diffused praecordial pain, and general hysterical 
phenomena. 

In a few cases the pain is absent, but all other symptoms are 
present — the " angina sine dolore " of Gairdner. Balfour claims that 
pain is not an essential part of the disease. He has probably never 
experienced an attack of true angina pectoris. 

Diagnosis. The points to be remembered are that the attacks 
are always paroxysmal, with long or short intervals, the patient hav- 
ing a sense of coldness, and frequently a cold sweat, the heart's 
action not increased, the chest fixed, and the breathing slow. 



DISEASES OF THE CIRCULATORY SYSTEM. 395 

Prognosis. True angina pectoris is unfavorable, the patient, 
sooner or later, either succumbing during the paroxysm or from 
exhaustion, the result of the cardiac changes. 

Pseudo-angina is always favorable. 

Treatment. During the interval between the attacks an attempt 
should be made to remove the exciting cause or diminish its predis- 
posing influence. 

For the organic form, no one remedy is comparable with a long 
course of potassii iodidum, gr. x-xx (0.6-1.3 Gm.), three times daily, 
as the frequency and intensity of the attacks are often diminished 
and a fair number of cases are retarded, proving the axiom, " the 
iodides are the digitalis of the arteries." 

The efficacy of the iodides is greatly enhanced and the course of the 
disease favorably influenced by adding full doses of nitroglyeerinum. 

For the nervous form, all violent emotions and active physical ex- 
ercise are to be avoided, the diet regulated, and the excretions watched. 
Among the drugs that are useful are ferrum, arsenicum, strychnina, 
phosphorus, and zincum. If the cardiac action be weak, use stro- 
phanthus. Trousseau urges the administration of belladonna in 
continuous small doses, on the ground of the analogy of the affection 
to epilepsy. Quain states that a continuous current, the positive pole 
on the sternum and the negative pole on the lower vertebras, lessens 
the severity and frequency of the anginal paroxysms. 

For the attack, prompt relief follows the use of amy I nitras, rt^iij-v 
(0.2-0.3 Cc), inhaled at the instant, or morphines sulphas, gr. %-%. 
(0.016-0.032 Gm.), to which may be added with advantage atropines 
sulphas, gr. yi^ (0.00065 Gm.), hypodermically, or nitro-glycerinum, 
gr. A * g^ (0.00065-0.0013 Gm.), every hour or two. In many cases 
the use of gr. yi^- (0.00065 Gm.) of this powerful drug, three or four 
times a day for a long time, lessens not only the frequency, but the 
severity of the paroxysms. Chlorodyne, rtl,x-xv (0.6-1 Cc), repeated, 
often affords relief. Chloroformum has proven prompt, efficient, 
and harmless administered as suggested by Balfour — viz., "a half 
drachm (2 Cc.) is poured upon a sponge at the bottom of a wide- 
mouthed bottle, from which the patient may breathe ad libitum''' 
Dr. William Evans recommends sparteines sulphas, gr. }( (0.016 
Gm.) three times daily, between attacks, to prolong the interval and 
lessen the severity of the paroxysms. 

Great care must be exercised with the diet that flatulency and con- 
stipation do not occur. 



396 PRACTICE OF MEDICINE. 



ARTERIO-SCLEROSIS. 



Synonyms. Atheroma; arterio-capillary fibrosis (Gull and Sut- 
ton) ; endarteritis chronica deformans (Virchow). 

Definition. A chronic degenerative and inflammatory disease 
of the vascular system, resulting in an overgrowth of the con- 
nective tissues of the arteries, followed by calcareous deposits. The 
changes may extend to the capillaries and veins. As a result of the 
impairment of the arterial circulation, occur fibroid degenerations in 
other organs, resulting in loss of elasticity in the walls of the vessels, 
increase of arterial tension, narrowing of the calibre of smaller 
arteries, and impairment of the nutrition of the organs supplied. 

Causes. Old age, as "longevity is a vascular question, and has 
been well expressed in the axiom that "a man is only as old as his 
arteries " (Osier). Heredity is a factor, as arterial degenerations occur 
in some families at a very early age — thirty to forty years. Alcoholism, 
syphilis, and other excesses predispose to arterial changes. Lead- 
poisoning, diabetes, malaria, gout, and rheumatism. Chronic nephri- 
tis. More common in men than in women. 

Pathological Anatomy. The atheromatous changes are most 
frequent in the aorta. Rokitansky gives the relative order in which 
atheromatous degenerations occur as follows, aorta, splenic, femoral, 
iliac, coronary arteries of the heart, arteries of the brain, uterine, sub- 
clavian, brachial, ulnar, and radial. 

The internal surface of the affected vessels is irregularly thickened 
with either gelatinous and translucent, or dense and fibrous, or 
calcareous deposits or products. If the calcification is extensive, the 
vessel is changed into a hard, stiff tube. Often the surface of the 
thickening or deposit is destroyed, presenting the so-called "ather- 
omatous ulcers," which may be covered with masses of thrombus. 

The above conditions are the result of inflammatory change in the 
intima of the affected vessel. This appears three or four times as 
thick as normal, due to the swelling of its elements, the new growth 
of connective tissue and the deposit of round cells. Fatty degenera- 
tion of the inflammatory products results. 

The result of the changes in the arteries is a loss of their elasticity, 
thus hindering the propulsion of the blood current and raising the 
arterial tension, leading to hypertrophy of the left ventricle. The 



DISEASES OF THE CIRCULATORY SYSTEM. 397 

changes finally involving the coronary arteries lead to alterations in 
the myocardium. If the intima of the smaller vessels be involved, 
the blood current to the organs supplied is lessened, resulting in a 
disturbance of their nutrition. 

Symptoms. Not always apparent. The symptoms vary with 
the arteries involved and the organs whose blood supply is lessened 
or cut off. 

Cardiac hypertrophy from the increased resistance to the arterial 
circulation. 

The peripheral arteries involved in the atheromatous changes can 
be determined by palpation, they having a hard, bony feeling, much 
like a whip cord. 

Attacks of vertigo, pseudo-apoplectic attacks, or spells of uncon- 
sciousness in the aged or those having superficial hardened arteries 
are generally due to changes in the cerebral vessels. Evidences of 
myocarditis and angina pectoris point to atheroma of the aorta and 
coronary arteries. Gangrene of the extremities in the old — senile 
gangrene — point to atheroma or thrombi, the result of the fibrosis. 

Palpation. Hard, superficial arteries, those at the wrist feeling 
like a string of beads, pulsating. The cardiac impulse is forcible in 
the early stages. 

Percussion. Increased precordial dullness, particularly over the 
left ventricle. 

Auscultation. In the early stages the first sound of the heart 
is prolonged, the second sound accentuated over the aortic cartilage. 
As the heart dilates and the walls become diseased, the sound be- 
comes feeble and often irregular and intermittent. 

Diagnosis. Only determined by a close study of the various 
symptoms and sequelae. 

Prognosis. Incurable. 

Treatment. Regulate the manner of living and the diet. Pre- 
vent constipation, and torpid liver and kidneys. No remedy can 
remove the fibroid changes, but a very considerable experience has 
convinced me that much comfort and prolongation of life follows the 
constant use several times a day for months and years of nitro-glyc- 
erinum, gr. -j-j^ (0.00065 Gm.), and long courses of potassii iodidian. 



398 PRACTICE OF MEDICINE. 



ANEURISM OF THE AORTA. 

Varieties. I. Aneurism of the arch of the aorta. II. Aneurism 
of the thoracic aorta. III. Aneurism of the abdominal aorta. 

The arch of the aorta is divided by Gray into three parts — the as- 
cending, the transverse, and the descending. 

The ascending portion is two inches in length, arising from the left 
ventricle, on a level with the lower border of the left third costal 
cartilage, behind the left edge of the sternum. It ascends obliquely 
upward to the right to the upper border of the right second costo- 
sternal articulation. The transverse portion commences at the upper 
border of the right second sternal articulation, and, arching to the left 
and forward, passes in front of the trachea and oesophagus to the left 
of the third dorsal vertebra. The descending portion extends down- 
ward to the left side of the fourth dorsal vertebra. 

The thoracic aorta extends from the left lower border of the fourth 
dorsal vertebra, and ends in front of the body of the twelfth dorsal 
vertebra, at the aortic opening in the diaphragm. 

The abdominal aorta begins at the aortic opening in the diaphragm, 
descends a little to the left side of the vertebral column, and termi- 
nates over the body of the fourth lumbar vertebra, where it divides into 
the two common iliac arteries. 

Definition. A circumscribed dilatation of some portion of the 
aorta, the result of disease of the vessel wall weakening its resistance 
to the blood pressure. 

Causes. Those causing arterio-sclerosis are the chief causes. 
Exertion is an exciting cause. Aneurisms occur in early middle life 
rather than in old age, when the force of the heart has decreased. 
More common in men than in women. 

Pathological Anatomy. All aneurisms may be divided into 
two classes, dissecting and circumscribed. 

Dissecting A?ieurism — false aneurism — is the result of fatty changes 
in the internal and middle coats of the artery. The shape may be 
sacculated, fusiform, or cylindrical. A disease of the aged. Cir- 
cumscribed Aneurism may be true or false, depending on the rupture 
of the walls or not. It is a disease of middle life or under. Most 
frequent in men, usually a true dilatation. Syphilis is a very fre- 
quent cause. 



DISEASES OF THE CIRCULATORY SYSTEM. 399 



ANEURISM OF THE ARCH. 

Symptoms. The onset is usually gradual, with evidences of 
arterio-sclerosis and failing health. 

Pain, either paroxysmal or constant, is a continuous symptom, with 
increasing dyspncea. The difficulty in breathing may be constant 
with exacerbations, or it may be remittent. Rarely dysphagia occurs. 
A slight cough from pressure on the laryngeal nerve, with more or 
less alterations in the voice, may be present. The pupils are dilated 
or contracted or are irregular, in some cases due to pressure on the 
sympathetic nerve. There is a gradual loss of flesh, disorders of the 
circulation, and a careworn expression of the face. 

Inspection. Negative until the appearance of a pulsating tumor. 

Palpation. A pulsation over the tumor, expansile in character 
(Corrigan's sign). 

If the aneurism is situated at the transverse portion of the arch, the 
left pulse and the left carotid are smaller and weaker than those on 
the right side. Tracheal tugging is a diagnostic sign (Page). " Place 
the patient in the erect position, with his mouth closed and chin 
elevated to the fullest extent. Then, on grasping the cricoid cartilage 
between the fingers and thumb and making gentle traction upward, 
the pulsations of dilated aorta or aneurism, if any exist, will be dis- 
tinctly felt, in most cases transmitted through the trachea to the hand." 

Percussion. Dullness, the extent depending on the size of the 
tumor. Dullness, other than cardiac, across the sternum is diagnostic 
of a mediastinal tumor. 

Auscultation. Over the tumor a murmur or bruit is usually 
heard, synchronous with the first sound of the heart. It is louder 
than the systole, lower in pitch, and of a blowing character. 

Diagnosis. If the tumor can be seen or felt, the diagnosis is 
made, its location being determined by a study of the physical signs. 



ANEURISM OF THE THORACIC AORTA. 

Symptoms. The most constant symptom is deep-seated thoracic 
pain, constant or paroxysmal. Dysphagia is a frequent condition. 
There is seldom dyspncea, and alteration of voice and pupils does 
not occur. 



400 PRACTICE OF MEDICINE. 

Physical signs are usually wanting, and the diagnosis is rarely- 
made during life. 

I have seen three cases in which the only symptoms the patients 
complained of were pain of a deep-seated and boring character in the 
left shoulder, associated with a feeling of general fatigue. Death 
ensued in each of the three cases suddenly by a frightful hemorrhage 
from the mouth, death occurring in a few moments, and an autopsy 
revealed a thoracic aneurism pressing deeply in the upper left pul- 
monary lobe the size of a lemon, which had suddenly ruptured. 



ANEURISM OF THE ABDOMINAL AORTA. 

Symptoms. The chief and most constant symptom is pain at a 
circumscribed spot in the abdomen, or rarely diffused over the 
abdomen. Other symptoms depend upon the location of the aneurism, 
as they are the result of pressure. There is a gradual loss of health. 

Inspection. Usually negative unless the aneurism reach an 
enormous size. 

Palpation. A pulsating tumor in the abdomen to the left of the 
median line. The pulsation is synchronous with the first sound of 
the heart, and is expansile (Corrigan's sign) in character. 

Percussion. Dullness may be elicited if the tumor is large and 
the abdomen emaciated. 

Auscultation. Rarely a murmur or bruit is heard, systolic in time. 

Diagnosis. Abdominal aneurism and pulsating abdominal aorta 
may be mistaken for each other. The point of difference is, in the 
aneurism, the presence of the tumor with an expansile pulsation, 
while in pulsating abdominal aorta, the beating is like a pulsating 
cord, an up-and-down movement, not expansile. The condition of 
the patient is also important ; aneurism in males, at middle life, with 
changes in the vessels ; abdominal pulsation occurring in nervous 
women or effeminate men. 

Tumors located over the abdominal aorta may give rise to an ap- 
parent pulsation, causing them to be mistaken for an aneurism. The 
rule is, in all cases of abdominal pulsation, to place the patient in the 
knee-chest position ; if the tumor is aneurismal, the expansile pulsa- 
tion continues ; if not an aneurism but a cancer, impacted faeces, or 
other tumor, the pulsation at once ceases. 






DISEASES OF THE NERVOUS SYSTEM. 401 

Prognosis of Aortic Aneurisms. Unfavorable. The duration 
of life after the development of the aneurism is from one to four years. 

Treatment. A persistent effort should always be made to pro- 
mote clotting in the sac and the contraction of the tumor. 

The so-called Tufnell's method is the most successful for this pur- 
pose, its aim being to diminish the force and rapidity of the circula- 
tion, and, if possible, to increase the fibrinous deposit. Its essential 
element is absolute rest of mind and body, and a restricted diet ; the 
patient is kept absolutely in bed day and night for at least three 
months, and placed on the following diet : Breakfast — two ounces of 
bread with butter and two ounces of milk; dinner — two or three 
ounces of bread, same amount of meat, and two to four ounces of 
milk or claret wine ; supper — two ounces of bread with butter and two 
ounces of milk. At the same time potassii iodidum is administered in 
increasing doses to the physiological limit. 

Galvano-puncture is said to do good in some cases ; two needles 
inserted into the aneurism are connected with the poles of a galvanic 
battery, and a weak current is passed through the tumor. 

The various symptoms are to be met with their appropriate reme- 
dies, always having in mind the condition of the arterial wall allowing 
the rupture and dilatation. 



DISEASES OF THE NERVOUS SYSTEM. 



The diseases of the nervous system will be described under the 
following headings : 

I. Diseases of the cerebral membranes. II. Diseases of the 
cerebrum. III. Diseases of the spinal cord. IV. Diseases of the 
nerves. V. General or nutritional diseases. VI. Mental diseases. 



402 PRACTICE OF MEDICINE. 



DISEASES OF THE CEREBRAL MEM- 
BRANES. 



The brain is invested with two membranes — the dura mater and the 
pia mater, or pia-arachnoid. 

The dura lines the interior of the skull, and, in addition, supports 
and protects the brain. The falx is an extended process of the dura 
which extends into the longitudinal fissure ; the tentorium is a process 
of the dura separating the cerebrum and the cerebellum ; thefalcula 
is a process of the dura extending between the two hemispheres of 
the cerebellum. 

The blood supply for the dura is from the anterior, middle, and 
posterior meningeal arteries. The middle meningeal or medidural 
artery, a branch of the internal maxillary, is the largest of the three, 
and is the vessel usually involved in meningeal hemorrhage. 

The nerve supply (a mooted question) is undoubtedly received 
from the fifth or trigeminus pair of cranial nerves, irritation of which 
nerve supply may produce hyperesthesia, pain, reflex motor, and vaso- 
motor disturbances (Duret). The pia (which includes the arachnoid, 
after the suggestion of Tuke, and which Mills calls the arachiopia, 
ox pia arachnoid') is composed of two layers — the visceral layer and 
the parietal layer. This membrane is a vascular network held by 
connective tissue. The visceral layer of the pia (formerly known as 
the pia alone) closely invests the brain everywhere, dipping into 
the fissures and into the ventricles. The parietal layer (formerly 
known as the arachnoid) closely covers the dura in all its parts. 

The pia arachnoid is the nutritive covering of the brain, supplying 
a considerable section with blood. The vessels of the pia lie on the 
surface and are encased in perivascular sheaths composed of the 
denser portions of the membrane. These perivascular spaces are the 
lymph-canals accompanying the blood-vessels into the brain-sub- 
stance and communicating with the subarachnoid spaces or cisterns. 

The nerve supply of the pia arachnoid is still in dispute, the mem- 
brane being generally considered without sensation. This is proba- 
bly an error. 



DISEASES OF THE CEREBRAL MEMBRANES. 403 

The Pacchionian granulations are always present in abundance 
" on the outside of the dura, on its inner surface, on the arachnopia, 
and within the superior longitudinal sinus and the parasinoidal spaces, 
or lacs sanguinis. They often indent the calvarium, and in rare 
instances they penetrate it. It is generally conceded that they are 
enlargements of the normal villi or tuft-like elevations of the parietal 
layer of the pia (arachnoid). Repeated attacks of meningeal hyper- 
emia probably assist in their development" (Mills). 



PACHYMENINGITIS. 

Synonyms. Meningitis ; hematoma of the dura mater. 

Definition. Inflammation of the dura mater ; when the external 
layer is primarily involved, it is termed pachymeningitis externa ; 
when the internal layer is primarily involved, it is termed pachymen- 
ingitis interna. 

Causes. Pachymeningitis externa is a surgical malady, resulting 
from fractures, penetrating wounds, and other injuries of the skull. 

Pachymeningitis interna is due to blows upon the head without 
injury to the skull, chronic alcoholism, scurvy, Bright's disease, tuber- 
culosis, and syphilis. Chronic internal otitis and suppurative inflam- 
mation of the orbit may cause it, and also inflammation in the venous 
sinuses the result of a thrombus undergoing suppurative changes. 
Following erysipelas, sun-stroke, and gout are recorded causes. 

Pathological Anatomy. Pachymeningitis interna. Hyper- 
emia of the membrane, followed by an exudation which develops 
into a membranous new formation, containing a great number of 
vessels of considerable size, but having very thin walls. Hemor- 
rhages from these new vessels are of frequent occurrence, which in- 
crease the size and thickness of the neo-membrane. 

The usual position of the neo-membrane or new formation is on 
the upper surface of the hemispheres, extending downward toward 
the occipital lobe. The changes in the adjacent portion of the brain 
are dependent on the size and thickness of the neo-membrane. 
Bartholow observed a case in which the " cyst " was half an inch in 
thickness at its thickest part, and it depressed the hemisphere corre- 
spondingly, the convolutions being flattened, the sulci almost obliter- 
ated, and the ventricle lessened one-half in size. 



404 PRACTICE OF MEDICINE. 

In pachymeningitis syphilitica, the pathological lesion is in the form 
of gummatous tumors or masses which may degenerate and become 
either cheesy masses or be converted into a purulent-looking fluid. 

In old age the dura mater becomes thick, cartilaginous, and of a 
dull white color. The sheaths of the arteries are also thickened. 

Symptoms. Very obscure ; principally those of cerebral pres- 
sure. Cases of persistent headache, vertigo, photophobia, anorexia, 
insomnia, gradual impairment of intellect and locomotion, followed 
by delirium, and convulsions and coma, or by apoplectic attacks and 
paralysis, occurring in the aged, or those in whom some one of the 
causes of the affection are present, an inflammation of the dura mater 
may be suspected. Epileptic attacks (dural epilepsy) sometimes occur. 

Circumscribed painful oedema behind the ear and less fullness of 
the jugular of the corresponding side, the phlegmasia alba dolens en 
miniature of Griesinger, are indicative of thrombosis in the transverse 
sinus, as was first shown by Virchow. 

Diagnosis. Always problematical, as the symptoms are masked 
and so obscure that a positive diagnosis is impossible. In very many 
instances the condition was not discovered until an autopsy. 

Prognosis. Most unfavorable for either forms, although the 
course of the malady is usually slow. Surgical treatment in traumatic 
cases offers some hope. 

Treatment. Pachymeningitis externa is to be treated surgically. 
Trephining is indicated in some cases. It is claimed that benefit 
has followed a thorough course of potassii iodidum. In the great 
majority of cases, however, all that can be done is to treat symp- 
toms. 



ACUTE LEPTOMENINGITIS. 

Synonyms. Acute meningitis ; cerebral fever ; arachnitis. 

Definition. An acute exudative inflammation of the cerebral pia 
mater and arachftoid 7nembraties (pia arachnoid, or arachnopia), 
usually limited to the convexity of the cerebrum ; characterized by 
fever, vomiting, headache, delirium, and followed by symptoms of 
general collapse. 

Causes. During the course of the acute infectious diseases ; ery- 
sipelas ; associated with or a sequela of influenza and typhoid fever. 
Cerebral overwork ; prolonged wakefulness ; acute alcoholism ; ex- 



DISEASES OF THE CEREBRAL MEMBRANES. 405 

posure to the sun ; syphilis ; blows on the head ; disease of the internal 
ear ; secondary to diseases of serous membranes. Most frequent in 
early adult life and in young children, and in males rather than 
females. 

" The micro-organisms found in meningitis are the pneumococcus, 
streptococcus pyogenes, intracellular diplococcus, the pneumo-bacil- 
lus, and a bacillus resembling that of typhoid fever " (Dana). 

Pathological Anatomy. The inflammatory changes may be 
limited either to the convexity or to the base of the brain, but more 
frequently both portions are involved. 

Intense hypercemia of both membranes, followed by a purulent and 
fibrinous exudation. The ventricles may be filled with fluid, com- 
pressing and flattening the convolutions. 

In twenty-five post-mortem examinations at the Philadelphia Hos- 
pital a meningo-encephalitis was present in fourteen. 

Symptoms. Keeping in mind the anatomy of the cerebral 
membranes and the extent of surface that may be involved in an 
inflammation, it will be seen how varied may be the symptoms of 
leptomeningitis. 

Prodromes : Headache, vertigo, cerebral vomiting, more or less 
feverishness, continuing from a few hours to one or two days, when 
occurs the 

Stage of Invasion : Onset with a chill, high fever, io3°-io4° ; a pulse 
100-120; face flushed with congested eyes ; severe headache, most 
intense and continuous; ringing in the ears, photophobia, vertigo, 
the nausea aggravated ; projectile vomiting, with delirium ; general 
hyperesthesia to the touch. 

Stage of Excitation : General sensibility of the body, increased with 
sensitiveness to light and acuteness of hearing ; delirium furious, 
often resembling mania ; continual jerking of the limbs, oscillations 
of the eyeballs (nystagmus), -twitching of the muscles of the face, 
followed by powerful contractions of the flexor muscles, even to the 
extent of opisthotonos, and in children convulsions ; coated tongue, 
constipation and retracted abdomen. Duration, from one day to a 
week or two. 

The finger drawn across the surface leaves a red line, the tache 
cerebrate. 

Stage of Depression or Collapse ; the patient gradually becomes 
more quiet, the delirium subsiding, as well as the muscular agitation ; 



406 PRACTICE OF MEDICINE. 

somnolence develops passing into coma, at times temporary conscious- 
ness, coma soon following again ; pulse irregular and slow, fever less ; 
various palsies, such as strabismus, ptosis, pupils uninfluenced by light, 
mouth drawn to one side, and urine and faeces involuntarily discharged. 
Death following either by convulsions or by deepening coma with 
cyanosis. 

Diagnosis. The characteristic symptoms indicating the existence 
of acute leptomeningitis are headache, vomiting, fever, and delirium, 
all developing rather rapidly. The headache is most persistent, and 
the vomiting not due to gastric trouble. The absence of any one of 
the four characteristic symptoms named above does not prove the 
absence of leptomeningitis, nor does the combination of delirium and 
fever alone determine the presence of meningeal disease. 

Cerebrospinal fever closely resembles acute leptomeningitis, the 
points of distinction between which are the first named occurring 
epidemically, associated with marked spinal symptoms and an 
eruption. 

Meningitis and abscess of the brain are apt to be mistaken for each 
other, the differential diagnosis being pointed out in the latter disease. 

The cerebral symptoms of rheumatism are differentiated from idio- 
pathic meningitis by the association of the joint trouble. 

Cerebral symptoms of typhoid and typhus fever have a close resem- 
blance to idiopathic meningitis, and are only determined by a study 
of the clinical history. 

In acute urce?nia the face is turgid, ©edematous, with puffiness of 
the eyelids ; in leptomeningitis the face is pale and no oedema; urae- 
mia has decided albuminuria ; it is slight or absent in leptomenin- 
gitis ; leptomeningitis has chills followed by fever ; uraemia has 
irregular temperature record, rapidly rising to 104 F.-106 F. and 
dropping to 99 F., to as rapidly rise again, and usually associated 
with convulsions. 

In delirium tremens the delirium is a busy one, the patient imagin- 
ing persons and animals around him, and is wild in his gestures and 
utterances ; the temperature is normal or subnormal, the skin wet 
and clammy. In leptomeningitis the delirium is mild but incoherent, 
the surface is hot and dry, and there is severe vomiting and head- 
ache. 

Prognosis. Not very favorable. If recognized early and treated, 
a fair number of recoveries occur, but it usually leaves the patient 



DISEASES OF THE CEREBRAL MEMBRANES. 407 

subject to attacks of epilepsy or with a persistent headache, and more 
or less mental impairment. Blindness and chronic internal hydro- 
cephalus are rare results. 

Treatment. Keeping in view the course and general prognosis 
of leptomeningitis, it is questionable if any very active medication 
will abate the disease during any stage. 

Bed-rest, quiet, in a well-ventilated room, with elevation of the 
head, and the use of a nutritious liquid diet, with attention to all the 
secretions, which are markedly disordered, and the application of 
cold to the head for the intense headache, and meeting the symptoms 
as they arise in the different stages of the disease, is the safer way to 
manage the majority of cases of leptomeningitis. Attempts at abort- 
ing the malady are depressing to the patient in the later periods of 
the malady. 

In vigorous or sthenic cases, with high febrile reaction and exag- 
geration of the early symptoms, a more or less vigorous venesection, 
or the use of leeches behind the ears, to the temples, or in the nuchal 
region, followed by the application of cold and the internal use of full 
doses of extractum ergotce fluidum every couple of hours, may be 
used. The cerebral circulation may be markedly influenced by com- 
pression of the carotids. 

For the vomiting use chloral, gr. iij-v (0.2-0.3 Gm.), per mouth, di- 
luted with aquae menthae f^ss (15 Cc), repeated in half hour and 
p. r. n., or by enema in doses of gr. x-xv (0.6-1 Gm.). The most 
refractory vomiting, of whatever cause, will yield to a few doses of 
this drug. 

If the disease show a disposition to linger, small doses of hydrargyri 
chloridum mite or polassii iodidum are of benefit. 

Third stage : Free stimulation, nutritious food, ferri iodidum, and 
flying blisters. 

TUBERCULAR MENINGITIS. 

Synonyms. Basilar meningitis ; acute hydrocephalus. 

Definition. An inflammation of the leptomeninges (soft mem- 
branes), particularly the basal pia mater, attended with or due to the 
deposit of gray miliary tubercle ; characterized by gradual decline 
of the bodily and mental powers. 

Causes. Usually a secondary affection, a sequel to tubercular 



408 PRACTICE OF MEDICINE. 

disease of some other organ. Most frequently occurs in children 
between two and six years of age, although numerous cases are 
reported occurring between twenty and thirty years; scrofulous (?) 
diathesis; inherited diathesis. The "gelatinous children of album- 
inous parents," as the phrase goes, possess a special susceptibility to 
tubercular meningitis. 

Pathological Anatomy. The deposition of tubercle usually 
occurs at the base of the brain. 

Depositions of grayish-white granules, of a translucent, somewhat 
gelatinous appearance — miliary tubercle, are distributed along the ves- 
sels of the pia mater, resulting in inflammation and the exudation of 
lymph, with the consequent thickening and opacity of the membranes. 

The cerebral tissue is not usually involved, although on section the 
lines indicative of blood-vessels are very much increased in number. 
The ventricles are distended by a clear, or milky, or even bloody 
serum. 

Tubercular deposits occur in the lungs, intestines, and, at times, in 
other organs. 

The presence of the tubercles alone may give rise to no symptoms 
until the exudative products of the resultant inflammation develop. 

Symptoms. The advent is either gradual and insidious, or with 
convulsions, in which cases the after progress is rapid. 

Prodro?nes : The child grows irritable, with loss of appetite, loss of 
flesh, swollen abdomen, constipation alternating with diarrhoea, 
irregular attacks of feverishness, with attacks of grinding the teeth 
during sleep, or sleeplessness. Headache occurs, as shown by the 
child, even when at play, suddenly stopping and resting its head on 
its hand or on the floor. Duration of this stage is from one week to 
a month or two. 

Stage of excitation : The onset is rather sudden, with obstinate 
vo?niting, severe headache, convulsions ; fever, io2°-io3° in the even- 
ing, falling to 99 in the morning; pulse soft and compressible, with 
irregular rhythm. On drawing the finger nail lightly over the surface 
a red line results, "the cerebral stain " of Trousseau. The symp- 
toms grow progressively worse with exaltation (hyperesthesia) of the 
special and general senses, the least pinch or even touch causing 
exquisite pain ; spas7nodic ?nove?nents of the muscles, with contraction 
and rigidity, at times opisthotonos. Duration of this stage is about 
two weeks to a month. 



DISEASES OF THE CEREBRUM. 409 

Stage of depression, the result of the pressure of the exudation ; the 
pulse is slow and compressible, with irregular rhythm ; te?nperature 
depressed ; tendency to somnolence alternating with quiet delirium, 
mental stupor, continual movement of the fingers, as in picking up 
objects; convulsions from time to time, strabismus, oscillation of the 
eyeballs (nystagmus), followed by intervals of wakefulness, when the 
headache is excruciating, causing the peculiar, unearthly shrill cry or 
shriek, "the hydrocephalic cry," associated with contraction of the 
muscles of the face, as if suffering were experienced; finally collapse 
occurring with the " Cheyne-Stokes " respiration, the co?na deepening, 
followed by death, convulsions often ending the scene. Duration, 
from a day or two to two weeks. 

Diagnosis. Acute leptomeningitis and tubercular meningitis 
have closely analogous symptoms during the stage of excitation, but 
the history and clinical course of the two maladies determine the 
diagnosis. 

Prognosis. Unfavorable. Usual duration, three or four weeks 
after fully developed prodromes. If ushered in by convulsions, the 
duration is shorter. 

Treatment. Most unsatisfactory. No means of retarding the 
disease. Treat symptoms as they develop. Blisters, leeches, active 
purgation, pustulating ointments, potassii iodidtim, and hydrargyrum 
are all useless. 

I If the hereditary tendency be marked, nutritious food, oleum mor- 
hu<2,ferri iodidu?n, and quinina may somewhat delay the develop- 
lent of the affection. 



DISEASES OF THE CEREBRUM. 



To understand the symptoms in diseases of the nervous system, a 
clear and precise knowledge of the anatomy and physiology is neces- 
sary. Presuming this knowledge, only a very few of the most ele- 
mentary facts will be mentioned before discussing diseases of the 
brain and cord. 
35 



410 PRACTICE OF MEDICINE. 

The nerve-cell 'is the real foundation of the nervous system. It re- 
ceives its nourishment from the arterioles and the lymphatics, and is 
drained by the venules, as are other tissues, and is supported by the 
connective tissue. Each nerve-cell has two processes, the axis- cylin- 
der process and the protoplasmic process ; the three — the cell and the 
two processes — are known as the neurons, the nervous system being 
made up of neurons. The axis-cylinder processes conduct the nerve 
impressions or current from the cells, and is a continuation of the 
axis-cylinder of the nerve. The protoplasmic process conducts the 
nervous current or impressions into the cell, and it is through these 
processes and their collaterals that the cell is brought into communi- 
cation with all portions of the body. The nerve-cells — "the very 
inner citadel of nervous life" — are mainly set in the gray matter of 
the brain and the spinal cord, and the axis-cylinder processes and 
the protoplasmic processes run in bundles or collections in the white 
matter of the brain and spinal cord. The gray matter of the brain 
and spinal cord, or the nerve-cells, is found chiefly in the cortex of 
the cerebrum and the basal ganglia, the cortex of the cerebellum, in 
the horns of the spinal cord and the nuclei of the medulla oblongata, 
and all these masses of gray matter or cells are connected by nerves, 
or the white matter, each protected by connective tissue. The cells 
endow the nerves with their particular functions. A knowledge of 
the physiology of the nervous system is essential to understand the 
functions of the different masses of gray matter, or cells, and of the 
nerves, or white matter. 

Without a knowledge of the known centers of "localization " it is 
impossible to interpret the symptoms of diseases of the nervous 
system. 

A knowledge of the blood supply of the brain is of practical im- 
portance, and particularly for understanding the symptoms and path- 
ology of apoplexy and cerebral emboli. 

The external carotids on each side supply blood to the scalp, the 
skull, and the dura mater. 

The internal carotid artery on each side and the vertebral arteries 
supply the brain, pia mater, and the eyes. 

The internal carotid arteries divide into the anterior cerebral and 
the middle cerebral arteries. 

The vertebral arteries on each side give off the inferior cerebellar 
arteries, and then join and form the basilar artery, which redivides, 



DISEASES OF THE CEREBRUM. 411 

forming the two posterior cerebral arteries, which, in turn, give off the 
posterior communicating artery. It is the uniting of these cerebral 
arteries by the anterior and posterior communicating arteries that 
forms the circle of Willis. From various portions of the circle of 
Willis and the beginnings of the anterior, middle, and posterior cere- 
bral arteries are given off six groups of vessels, which furnish the 
blood supply to the basal ganglia and the adjacent white matter, from 
which they derive their name, " the central arteries of the brain." 
The " central arteries " given off by the middle cerebral or Sylvian 
artery are of the most importance to the clinician. They are known 
as the lenticular-optic and the lenticular-striata arteries, and are 
usually involved in cerebral hemorrhage. 

The following centres have thus far been localized in the cortex — 
viz: the motor, vision, word-deafness, word-blindness, aphasia, 
agraphia, and muscular sense of pain and touch. The " mind " centre 
has been long considered as located in the frontal lobe, anterior to the 
motor area and the third frontal convolution, but of late the view is 
growing that for complete integrity of the mind the entire cortex must 
be intact, although lesions of the portions named produce mental 
symptoms only, while lesions of other portions of the cortex cause 
other disorders in which mental changes are more or less prominently 
observed. 

The many symptoms resulting from diseases of the brain can be 
placed in four groups : 

i. General symptoms of brain irritation. 2. General symptoms of 
brain pressure. 3. Symptoms of focal irritation or destruction. 4. 
Symptoms due directly to the pathological process. 

Symptoms of brain irritation, or hypersemia, are : headache, ver- 
tigo, vomiting, photophobia, mental irritability, insomnia, fullness or 
pressure over the brain, with scalp tenderness and noises in the ears. 
Rarely convulsive symptoms and delirium may occur. 

Symptoms of brain pressure are : headache, vomiting, mental dull- 
ness, and frequently some form of paralysis with contracted pupil 
and finally coma. 

Focal lesions depend upon their character: if irritative, convulsive 
or spasmodic phenomena if located in the motor area, and, if decided 
pressure or destructive lesions, paralysis, such as hemiplegia and 
aphasia. 

The symptoms of brain lesions due to the pathological process itself 



412 PRACTICE OF MEDICINE. 

have few if any paiticular symptoms other than those due to the loca- 
tion except in abscess or gummata, when the constitutional symptoms 
of suppuration, such as chills, fever, sweats, and prostration, are 
added to other brain symptoms. 



CONGESTION OF THE BRAIN. 

Synonyms. Cerebral hyperemia ; cerebral congestion. 

Definition. An abnormal fullness of the vessels (capillaries) of 
the brain : Active, when arterial fullness ; passive, when venous full- 
ness; characterized by headache, vertigo, disorders of the special 
senses, and, if the hyperaemia be decided, convulsions. 

Causes. Active. Increased cardiac action, the result of hyper- 
trophy of the left ventricle ; general plethora ; excesses in eating and 
drinking; acute alcoholism; sunstroke; prolonged mental labor; 
diminished amount of arterial blood in other parts, the result of 
the compression of the abdominal aorta or ligation of a large 
artery, or the suppression of an habitual bleeding hemorrhoid, are 
examples. 

Passive. Dilatation of the right heart ; pressure upon the veins 
returning the cerebral blood. 

While congestion of the brain is not so frequent as was once sup- 
posed, the view that it cannot occur is disproven by the results fol- 
lowing the inhalation of a full dose of amyl nitris. The relief of head 
symptoms after a free epistaxis and the distress resulting if it does 
not occur is another instance. 

Pathological Anatomy. The post-mortem appearances are : 
Overloading of the venous sinuses and of the meningeal vessels, in- 
cluding the finer branches; the pia mater appears vascular and 
opaque ; the gray matter of the convolutions unduly red ; the convo- 
lutions may be compressed and the ventricles contracted, with the 
displacement of a corresponding amount of cerebro-spinal fluid. 

Long-continued or repeated congestions lead to enlargement and 
tortuosity of all the vessels, a moist and slimy condition (oedema) 
of the cerebral substance, and an increase in the sub-arachnoid 
fluid. 

Symptoms. "Rush of blood to the head" may be gradual or 



DISEASES OF THE CEREBRUM. 413 

sudden in its onset, the symptoms aggravated by the recumbent posi- 
tion. Headache, with paroxysmal neuralgic darts, disorders of vision 
and hearing, buzzing in the ears and sparks before the eyes, con- 
tracted pupils, vertigo, blunted intellect, inability to concentrate 
the mind, irritable teinper, and curious hallucinations. The face is 
red, the eyes congested, and the carotids pulsating. The sleep is dis- 
turbed by dreams and jerkings of the limbs. If the attack be sudden 
(apoplectiform), sudden unconsciousness with muscular relaxation 
occur. 

Cerebral hyperemia in children often presents alarming symptoms, 
such as great restlessness, insomnia, night-terrors, gnashing of the 
teeth during sleep, vomiting, contraction of pupils followed by general 
convulsions. Any or all of these symptoms may continue more or less 
marked from an hour or two to a day, the child enjoying its usual 
health, after a sound sleep, save a feeling of fatigue. 

Prognosis. Mild cases terminate favorably in a few hours to a 
day or two, but show a strong tendency to recur. Severe cases (apo- 
plectiform) may terminate in health, but usually foretell cerebral 
hemorrhage. 

The passive form is controlled by the lesions giving rise to it. 

Treatment. Active form ; Remove the cause if possible. Elevate 
the head and apply cold, either cold cloths or the ice cap ; at the same 
time warmth to the feet. Leeches to the mastoid, or cups to the neck, 
or in the apoplectiform variety venesection, to diminish the intracranial 
blood pressure ; compression of the carotids, or ligatures about the 
thighs, have been recommended. 

An active purgation is indicated, either by oleum tiglii, or magnesii 
sulphas, by the mouth. The following enema is often valuable : 

R . Magnesii sulphatis, f, ij 60. Gra. 

Glycerini, f^j 30. Cc. 

Aquae bul., fjiv 120. Cc. M. 

Sig. — Administer slowly per rectum, with little force. 

In mild cases the application of an ice cap to the head, sinapis to 
the nucha, and potassii bromidum, gr. xxx-xl (2-2.6 Gm.), repeated, 
and the enema mentioned above, control the symptoms. Extraction 
ergotcE fluidum is strongly recommended, but its value seems to be 
overestimated. 



414 PRACTICE OF MEDICINE. 

In severe cases, with forcible, overacting heart, to the above means 
must be added tinctura veratri viridis or tinctura aconiti. 

Passive form : Becomes a part of the treatment producing the 
stasis. 



CEREBRAL ANAEMIA. 

Definition. An abnormal decrease in the quantity of blood in 
the cerebral vessels ; general, when the diminished supply includes 
all the vessels ; partial, when the diminished supply is limited in 
area ; characterized by pallor, headache, vertigo, some loss of power, 
and, rarely, convulsions. 

Causes. Partial cerebral anaemia results from obstruction of a 
vessel, from embolism or thrombosis. General cerebral anaemia re- 
sults from hemorrhages, wasting diseases, during convalescence from 
severe attacks of fevers, sudden shock, feeble cardiac action, and 
general anaemia. 

Pathological Anatomy. The functional activity of the brain 
depends upon the quantity and quality of the blood circulating in 
the cerebral capillaries. Any decrease in the normal quantity or 
impairment in the quality produces the symptoms of cerebral anaemia. 
The brain is pale and milky in color, and on transverse section there 
are no bloody points ; the ventricles and perivascular lymph-spaces 
are well filled with fluid. 

In partial anaemia the local conditions differ somewhat from the 
above. 

Symptoms. Ge?ieral : Headache, relieved by the recumbent 
position ; vertigo, aggravated by exertion ; general pallor, and anae- 
mia with attacks of fainting ; when the general cerebral anaemia is 
sudden and decided, convulsions occur. 

Partial ancemia ; sudden loss of power of limited muscular area, 
gradually returning to the normal condition. 

Prognosis. Favorable in all cases save those the result of severe 
and repeated hemorrhages. 

Treatment. Regulated nourishment, with stimtilanls. A certain 
number of hours daily in the recumbent position is of advantage. 
When a tendency to attacks of swooning exists, alcoholic stimulants 
or spiritus a?nmonia? aromaticus and spiritus cetheris compositus every 



DISEASES OF THE CEREBRUM. 415 

few hours or even the cautious inhalation of amyl nitris are indi- 
cated. To improve the quantity or quality of the blood — 

R. Tinct. ferri chlor., Tt\, xv *• Cc. 

Acid, phosph. dil., TT\,v .3 Cc. 

Liq. arsenici cbloridi, TT\^iij -2 Cc. 

Syr. limonis, f;5 ss 2 - Cc. 

Syr. zingiberis, . . . . q. s. ad fgij ad 8. Cc. M. 

Sig. — Every six hours, well diluted. 

Or— 

R. Strychninse sulph., gr. j .065 Gm. 

Quininae sulph. , gr. xlviij 3. 1 Gm. 

Acid, hydrochlorici dil., . . . f.^ij 8. Cc. 

Tinct. gentian, comp. , .... f.^iij 90. Cc. 

Tinct. card, comp., . q. s. ad f^vj ad 180. Cc. M. 

Sig. — Teaspoonful in water, after meals. 



CEREBRAL HEMORRHAGE. 

Synonyms. Apoplexy ; " a stroke." 

Definition. The sudden rupture of a cerebral vessel and escape 
of blood into the cerebral tissue, causing pressure and more or less 
destruction of the brain substance ; characterized by sudden uncon- 
sciousness, irregular, noisy respiration, and complete muscular relaxa- 
tion. 

Causes. Rare under forty years of age. The principal cause is 
disease of the vessels — the development of miliary aneurisms, or a 
chronic endarteritis with an associated cardiac hypertrophy ; heredi- 
tary tendency ; Bright's disease ; syphilis ; alcoholic and dietary ex- 
cesses, — chronic alcoholism is probably the most common cause. 
Apoplexy early in life is usually syphilitic. More frequent in the 
spring and autumn. 

Pathological Anatomy. The most common locations of cere- 
bral hemorrhage are the regions supplied by the " central arteries," 
the internal capsule, corpus striatum, and thalamus opticus ; less 
common, the cerebellum ; next in frequency the pons and medulla 
oblongata, and rarely on the convexity of the brain, termed menin- 
geal hemorrhage. 

Intracerebral hemorrhage is more common upon the right than 
upon the left side, and especially affects the region of the caudate 



416 PRACTICE OF MEDICINE. 

nucleus, lenticular nucleus, internal capsule, and optic thalamus ; and 
particularly the outer border of the lenticular body, which is supplied 
by the striate artery, — the artery of cerebral hemorrhage. These 
lenticular striate arteries are branches of the Sylvian artery, and have 
no anastomoses. 

When the hemorrhage is large, the blood may break into the ven- 
tricles and pass by the iter from the third to the fourth ventricle. 

A recent clot is dark in color, and in consistency a soft, grumous 
mass, composed of coagulated blood and brain substance in varying 
proportions, at whose centre is the opening into the ruptured vessel. 
The £•/<?/ excites inflammation around it, resulting in its being encysted, 
by the development of new connective tissue from the neuroglia, and 
then gradually absorbed, leaving a cicatrix ; or the brain tissue around 
the clot softens and degenerates — localized softening. 

Symptoms. The attack may occur suddenly as an apoplectic 
shock or stroke, or slowly with prodromes or "warnings." 

Prodromes: Headache, vertigo, transient deafness or blindness, 
sensation of numbness of the extremities, with local palsies, together 
with the constant dread of an attack. 

The attack may begin with vomiting, followed by either partial or 
complete insensibility, or, suddenly, the patient becoming at once 
unconscious and, if standing at the time, sinking to the ground com- 
pletely relaxed or, rarely, with spasmodic or convulsive movements; 
respiration slow, irregular, and noisy ; during the inspiration the 
paralyzed cheek is drawn in, and puffed out in expiration ; pulse 
slow and full ; pupils uninfluenced by light, the/ace flushed, the eyes 
congested, and the carotids throbbing ; the temperature declines below 
the normal a degree or two, but rises within twenty-four hours to ioo° 
F.-ioi F. In fatal cases the temperature may rapidly rise to io6° F. 
-108 F. 

The muscular system is profoundly relaxed, and the reflex move- 
7nents are abolished. The head and eyes deviate, in many cases, 
toward the affected side in the brain or from the paralyzed side. 
Rarely convulsions occur. 

Ingravescent apoplexy begins as a mild stroke with a rapid return to 
consciousness and power, except, perhaps, of speech. Headache is 
present with some one or more local symptoms, and in a few hours to 
a few days consciousness gradually becomes impaired, the loss of 
power again occurs, the coma deepens, the patient dying comatose. 






DISEASES OF THE CEREBRUM. 417 

If the unconsciousness continues longer than twenty-tour hours, 
death is the usual termination, preceded by pale face, irregular and 
rapid pulse and respiration, and rise of temperature. 

Reaction obtains in from a half to three hours, consciousness re- 
turning, reflex excitability reviving, associated with headache, con- 
fusion of mind, and more or less paralysis of motion and sensibility 
of one side of the body, termed hemiplegia. 

The electro-excitability of the paralyzed parts is preserved. 

Recovery may be delayed by inflammatory symptoms, the tem- 
perature rising to ioi°-io4° F., with tonic contractions {early rigidity) 
of the paralyzed muscles and severe neuralgic pains. 

Localization of the lesion of a cerebral hemorrhage is of great 
practical importance. 

Capsular Jie77iorrhage or of the internal capsule at the anterior 
portion around the genu (knee), where the motor fibres pass and con- 
verge coming from the hemispheres, is a frequent site, causing 
loss of consciousness of sudden or rapid onset, hemiplegia, involving 
face, arm, and leg, with motor aphasia if the hemiplegia be on the 
right side. There is also a unilateral loss of reflex action, conjugate 
deviation of the eyes from the paralyzed side, and unilateral defective 
movement with flaccidity of the limbs. 

Cortical hemorrhage , localized unilateral paralysis of the face, the 
arm, or the leg, with local convulsions or convulsions that have a local 
beginning, or profound unconsciousness. 

Centrmn ovale hemorrhages resemble the cortical with the local 
convulsions. 

Cms- cerebri hemorrhage, loss of consciousness with hemiplegia in- 
volving the lower half of the face and the limbs, with paralysis of the 
third nerve on the opposite side, or the side of the lesion. The uni- 
lateral third nerve symptoms are ptosis, external strabismus, dilata- 
tion of the pupil, and loss of accommodation for near objects. The 
paralysis is termed " crossed " or " alternate " hemiplegia. 

Pons hemorrhage causes either general convulsions or irregular con- 
vulsions in the legs, bilateral motor paralysis, bilateral anaesthesia, 
either contracted or dilated pupils, embarrassed respiration, repeated 
non-gastric vomiting, and high temperature. If the hemorrhage is 
large, death is sudden or within a few hours, and even if small, the 
prognosis is unfavorable. 

Ventricular hemorrhages are generally of the ingravescent variety, 
36 



418 PRACTICE OF MEDICINE. 

and are characterized by a second apoplectic seizure soon after the 
first, with extension of the hemiplegic symptoms or a relaxation of the 
muscles from one side to both sides of the body. 

Cerebellar hemorrhages vary so greatly in the symptoms that a 
positive diagnosis can seldom be made. 

Meningeal or dural hemorrhage is usually due to a trauma. Two 
varieties : I. Infantile meningeal hemorrhage, occurring during 
labor. II. Extra- dural hemorrhage, the result of direct injury to 
the head. 

The infantile variety presents symptoms of irritation and compres- 
sion of the cortex, such as convulsions, general or unilateral ; rigidity, 
opisthotonos, and either hemiplegia or diplegia. 

The extra-dural variety is almost always the result of fracture or 
trauma of the skull, resulting in an extravasation of blood between 
the dura and the skull from the middle meningeal artery ; the hem- 
orrhage may be on one or both sides. The symptoms may develop 
at once or after some days, and are those of pressure ; hemiplegia, 
partial or complete; convulsions, impaired or absent reflexes, dila- 
tation with loss of reaction of pupil of opposite side ; stupor, gradually 
deepening into coma and death. 

Sequelae. Paralysis of the muscles of the face, tongue, body, 
and extremities of one side, opposite to the location of the hemor- 
rhage, termed unilateral paralysis or right or left hemiplegia. 

Paralysis of both sides of the body, due to simultaneous hemor- 
rhage on both sides, termed bilateral hemiplegia, or diplegia. 

Paralysis of one side of the face and of the extremities of the oppo- 
site side, due to hemorrhage into the pons Varolii, termed alternating 
or crossed paralysis. 

Occasionally tonic contractions occur in muscles long paralyzed, 
termed late rigidity, and is evidence of a secondary degeneration of 
the nerve fibres. 

Choreic movements in paralyzed muscles are termed posthemi- 
plegic chorea, due, according to Charcot, to changes in the motor 
centres. 

The mental powers are always more or less permanently impaired, 
the patient irritable and emotional, and the same holds good con- 
cerning the memory. 

Diagnosis. The diagnosis of the apoplectic seizure is often one 
of the most difficult questions in medicine, and yet of the greatest 



DISEASES OF THE CEREBRUM. 419 

importance, as the treatment depends upon its correctness. The 
diagnosis of the sequelae is comparatively easy. 

Insensibility from drink differs from apoplexy in the following 
points: insensibility is not so complete, no drawing in and puffing 
out of one cheek with respiration, the pulse frequent instead of slow, 
the pupils influenced by light; upon raising both legs, no difference 
is apparent on allowing them to drop ; the eyes and head are not 
turned to one side, and, lastly, the condition is ameliorated on the 
inhalation of ammonia. Dr. von Wedekind's test for temulence is 
generally satisfactory : " By simply pressing on the supraorbital 
notches with a steadily increasing force you may, with certainty of 
success, bring an unconscious alcoholic to his senses, and thus differ- 
entiate between alcoholic and other comas." 

Opium poisoning differs from apoplexy by the gradual approach of 
the coma, the contracted pupil and slow pulse, and quiet, slow res- 
piration, and that the patient can be momentarily aroused, and also 
by the absence of the heavy -stertor of apoplexy. 

Urcemia causes a coma that closely resembles apoplexy. A history 
of Bright's disease at once clears up the case ; again, urasmic coma is 
generally preceded by convulsions ; a rapid rise of temperature, as 
shown by the thermometer, often 104 F. to 106 F., while to the hand 
the surface appears but little, if at all, above the normal ; the pulse 
is usually weak with irregular force, the respirations averaging 
twenty-five to thirty per minute, the face having a glossy appearance. 

Cerebral embolism cannot always be differentiated from apoplexy. 
We may suspect cerebral plugging if the patient be young ; if he be 
laboring under acute or chronic cardiac valvular trouble ; if, within 
brief periods, several incomplete attacks have occurred before a 
complete comatose condition obtains ; or, if hemiplegia results with 
passing or slight unconsciousness ; or, if the phenomena are sooner 
or later followed by cerebral softening, as embolism and thrombosis 
are the most common causes of softening. 

Syncope or a fainting-fit is of sudden onset, but, being due to a 
failure of the circulation, the pulse is feeble, the face pale, the respi- 
rations quiet, and the duration of unconsciousness short, all the very 
opposite of an apoplectic attack. 

Prognosis. If the patient survive the immediate effects of a 
cerebral hemorrhage, he is always in danger of a new attack, 
since the causes of the original attack still remain. Another attack 



420 PRACTICE OF MEDICINE. 

or two is the usual course, a fatal termination ultimately occurring. 
If the attack be due to or associated with Bright's disease, recovery is 
rare. 

The hemiplegia is uncertain ; a partial recovery may occur within 
a few months or it may continue for years. 

Treatment. If there are prodromal indications, the most prompt 
means of reducing the intracranial blood pressure is by venesection, 
followed by a brisk purgative, which may be aided by an immediate 
enema : 

R . Magnesii sulph. , % ij 60. Gm. 

Glycerini, f^j 30. Cc. 

Aquae bullae, fo^J 9°- Cc. 

SlG. — Administer by bowel slowly without force. 

If the patient be weak, however, leeches to the mastoid, and potassii 
bromidum, gr. xl-lx (2.6-4 Gm.), or extraction ergotce fluidum, f3ss-j 
(2-4 Cc), may be substituted. 

For the attack, loosen clothing, elevate the head, remove constric- 
tions, place in a cool room, have perfect quiet, placing the patient 
sufficiently on his side, with the face somewhat downward, for the 
tongue and palate and secretions to fall forward instead of backward 
into the pharynx, and at once venesection, cold to head, a mustard 
foot bath, and oleum tiglii, Ti\J— iij (0.06-0.2 Cc), with glycerinum , tt\, xv 
(1 Cc), placed on back of tongue ; if the pulse be full and strong, 
when consciousness is regained, either tinctura veratri viridis or 
tinctura acofiiti is indicated. 

If during the attack the face be pallid and the pulse irregular, and 
the patient is prostrated by the shock, stimulants and digitalis are in- 
dicated, with, perhaps, leeches to the mastoid and an enema of tere- 
binthina. 

For the secondary fever, either tinctura aconiti or- tinctura veratri 
viridis ; for the headache and delirium, camphorce bromidum. 

For promoting the absorption of the clot, keep the secretions active, 
a good diet and a course of potassii iodidum or hydrargyri chloridum 
corrosivum, alternated with — 

H. Liq. potassii arsenit. , TT^ v .3 Cc. 

Syr. calcii lacto-phosph., . . .f^ij 8. Cc. 

Three times a day. 

After two or three months a weak galvanic current applied directly 



DISEASES OF THE CEREBRUM. 421 

to the brain, by placing an electrode on each mastoid process, pro- 
motes absorption. 

F 'or the paralyzed muscles, the faradic current, applied by placing 
one electrode over or near the nerve innervating the muscle and the 
other over its belly, acts as a tonic, preventing wasting ; it is assisted 
by hypodermic injections into the paralyzed muscles of strychnine 
sulphas, gr. g^ (o.ooi Gm.), four times a week. 



CEREBRAL THROMBOSIS AND EMBOLISM. 

Synonyms. Partial cerebral anaemia ; occlusion of cerebral 
vessels ; cerebral apoplexy (?). 

Definition. The occlusion of a cerebral vessel, from the forma- 
tion of a thrombus or the presence of an embolus, thus causing anamia 
of some portion of the brain ; characterized by the gradual — when the 
result of thrombosis, and the sudden, when due to embolism — devel- 
opment of headache, vertigo, disorders of intelligence, with more or 
less complete insensibility and paralysis. 

Causes. Thrombosis, or the formation of a clot in the vessel, — 
an ante-mortem coagulation, — is almost always the result of chronic 
endarteritis, as seen in the aged, together with a slowing and weaken- 
ing of the blood current. Chronic alcoholism and syphilis are the 
usual causes when occurring in young adults. 

Emboli, in the great majority of instances, result from an endocar- 
ditis — cardiac emboli ; small particles of the exudation being carried 
into the circulation and deposited in the brain. Emboli may also be 
derived from an aortic aneurism or syphiloma of the great vessels. 

Pathological Anatomy. The cerebral arteries may be ob- 
structed by emboli or thrombi : the cerebral veins and sinuses by 
thrombi only. The changes in the cerebral tissue are those of anaemia 
of the part or parts supplied by the occluded vessels. The subsequent 
changes depend upon the anatomy of the vessels. If the obstructed 
artery has anastomoses, the collateral circulation is soon established 
and the brain tissue assumes its normal condition. If, on the other 
hand, the occluded vessel be one of " Cohnheim's terminal arteries," 
— arteries without anastomoses, such as the lenticular-optic and the 
lenticular-striate set of arteries, branches of the Sylvian artery, — 
the blood in the whole extent of the occluded vessels coagulates, 
thus preventing the backward flow of blood from the surrounding 



422 PRACTICE OF MEDICINE. 

capillaries and so obstructing collateral circulation, whence the 
anaemic tissue dies or undergoes necrobiosis, followed by yellowish- 
white softening ; or, if the vessel beyond the seat of the occlusion 
remains pervious, blood flows back through the capillaries from the 
nearest artery or vein, the parts that a short time before were blood- 
less, now become deeply engorged, the succeeding changes in the 
vessels permitting diapedesis of the red blood globules. The tissues 
which are undergoing disintegration are colored by the red globules, 
causing the appearance entitled "red softening," which after some 
weeks becomes "yellow softening," finally changing to "white 
softening," when there is a milky, or rather creamy fluid mixed with 
masses or particles of broken-down nerve elements. 

The vessel most commonly occluded is the left middle cerebral 
artery, which sends branches to the second and third frontal convo- 
lutions, the anterior and superior portions of the three temporal 
convolutions, the island of Reil, the parietal convolutions, part of the 
external and all of the internal capsule, the lenticular nucleus, and 
most of the corpus striatum, — the motor centres. 

Symptoms. Two distinct modes of onset : Gradual, when the 
result of thrombosis ; sudden or apoplectic, when due to embolism. 

Cerebral thrombosis : Most common in the aged. Persistent head- 
ache and vertigo, at one time severe and at another mild. Next, 
alterations in the patient's character; irritable, morose, and despondent, 
with periods of absent-mindedness , disorders of vision, and impairment 
of meiiiory, speech becoming hesitating and mumbling. Impaired 
locomotion, the result of the vertigo, and of muscular weakness and 
trembli?ig, followed sooner or later by hemiplegia, which may be 
preceded by sudden insensibility or occur gradually, the symptoms 
slowly proceeding to dementia and death from exhaustion ; or, 
rarely, the symptoms are not so grave, and partial or complete re- 
covery occurs after the hemiplegia, from establishment of the "col- 
lateral circulation." 

Cerebral embolism. The symptoms are sudden, but either mild or 
grave in character. 

Mild variety ; sudden and severe vertigo, confusion of mind, mus- 
cular twite hings, usually one-sided, and vomiting, followed by hemi- 
plegia, most frequently of the right side, the intellect clear but hesi- 
tating. After some weeks or months the paralysis usually disappears 
and recovery is complete. 



DISEASES OF THE CEREBRUM. 423 

Grave or apoplectic variety. Sudden headache, vertigo, flushing 
ox pallor of the face, or the patient may utter a sharp cry, fall to the 
ground with sudden unconsciousness and complete muscular relaxa- 
tion, followed by death or a gradual return of consciousness with 
hemiplegia, which is generally right-sided, with aphasia, remaining for 
several weeks or months, or is persistent, the mind re??taining nonnal 
or enfeebled and the emotional nature highly excitable and the reason 
and judgment clouded, continuing thus for years, or gradually devel- 
oping into dementia, exhaustion, and death. 

The following are some of the symptoms of " localization " if par- 
ticular vessels are blocked : 

Vertebral artery, the left most frequently, results in acute bulbar 
paralysis from involvement of the nuclei in the medulla, associated 
or not with hemiplegia. 

Basilar artery causes diplegia with bulbar symptoms. There is 
rapid rise of temperature. Death follows within a day or two, or sud- 
denly, if the respiratory centres are involved. 

Middle cerebral artery or one of its branches is the most frequent 
seat of embolic or thrombotic occlusions. The symptoms depend 
upon the exact branch involved ; if plugged before the central arteries 
are given off, the internal capsule is deprived of its blood supply 
and permanent hemiplegia may follow ; if the blocking is in the 
central branches, the hemiplegia involves the arm and face, and if 
the left side, aphasia occurs. The individual branches passing to the 
third frontal (aphasia), the ascending parietal (hemiplegia, particularly 
hand), supra-marginal and angular gyri (word blindness), and the 
temporal gyri (word deafness), may be plugged. 

Duration. Thrombosis, essentially an affection of the elderly, and 
has a chronic course. Months and years may be occupied with the 
various symptoms until the phenomena of secondary dementia de- 
velop. 

Embolism is of sudden onset, and may be followed by a rapid 
recovery. 

Diagnosis. — Thrombosis is associated with changes in the ves- 
sels, the arcus senilis, and other evidences of senile degeneration. 

Embolism may be mistaken for cerebral apoplexy, and, while a 
positive differentiation cannot always be made, an important point to 
be considered is the presence of cardiac murmurs. 

Prognosis. Thrombosis is a permanent and progressive condition 
in the majority of instances. Recovery is a rare termination. 



424 PRACTICE OF MEDICINE. 

Embolism may be followed by a perfect recovery. Usually, how- 
ever, some evidences of the plugging remain permanently. Death 
may be the result within a day or two, from the plugging of a large 
vessel, the patient never emerging from the coma. In other cases the 
patient arouses from the coma, the hemiplegia with aphasia persisting, 
and the case pursues the usual course of localized cerebral softening. 

Treatment. The indication in the early stage of embolism and 
thrombosis is the re-establishment of the circulation within the area 
deprived of its blood supply, in order to prevent the changes incident 
to defective nutrition ; this is accomplished by measures to strengthen 
the heart's action, tonics, perfect rest for some time after the attack, 
a plain but nutritious diet, and attention to the various secretions. 

Prof. Bartholow "has had remarkable results from the following 
plan of treatment in thrombosis " : Ammonii carbonas, gr. x (0.6 Gm.), 
with ammonii iodidum, gr. v (0.3 Gm.), three times a day, continued 
for several months, " the object being dual — to increase the action of 
the heart and arteries, and to effect a solution of thrombi forming by 
maintaining the alkalinity of the blood." 

In the aged, presenting indications of degeneration, much benefit 
results from the use of — 

$ . Liquor, potassii arsenitis, . . . mjij .2 Cc. 

Syr. calcii lacto-phosphat. , . . . f 3 ij 8. Cc. M. 

SlG. — After meals, well diluted. 

It may be combined with oleum morrhuce with decided advantage. 
For embolism, the immediate and persistent use of the following 
may dissolve the plug : 

R. Ammonii carbonat., gr. v .3 Gm. 

Liquor, ammonii acetatis, . . . fgj 4. Cc. M. 

SlG. — Three or four times daily, well diluted. 

" In a month or two a very light galvanic current (from two cups) 
may be passed through the brain in both directions " (Bartholow). 



CEREBRAL ABSCESS. 

Synonyms. Acute encephalitis ; suppurative encephalitis. 

Definition. An acute suppurative inflammation of the brain 
structure, either localized or diffused, primary or secondary ; charac- 
terized by impairment of intellect, sensation, and motion. 



DISEASES OF THE CEREBRUM. 425 

Causes. Primary cerebral abscess is exceedingly rare. Pyaemia ; 
glanders ; embolus from ulcerative endocarditis. 

Secondary cerebral abscesses result from injuries to the cerebral 
tissues, following apoplexy, embolism, thrombosis, .and injuries to the 
cranial bones. Chronic suppurative otitis ; chronic suppuration in 
some other portion of the body. 

Pathological Anatomy. Abscesses of the brain may be single 
or multiple, varying in size from an almond to an egg. 

It occupies a limited and well-defined region of the cerebral tissue, 
such as either the corpora striata, optic thalami, gray matter of the 
cortex, the cerebellum, or the white matter of the hemispheres. 

Cerebral abscesses are usually due to micro-organisms. Abscesses 
are more frequent in the right hemisphere than the left. When the 
result of pyaemia or infection from distant organs, such as the lungs, 
they are generally multiple. When secondary to disease of the ear, 
frontal sinuses, nasopharynx, or trauma, they are generally single. 

An abscess having developed, steadily increases in size, encroach- 
ing upon the surrounding brain, and usually the brain tissue forms a 
defensive wall about the abscess — a capsule or pyogenic membrane. 
The incapsulated abscess continues to develop, finally bursting, in- 
filtrates the surrounding tissue with consequent pressure, or discharges 
into the meshes of the pia arachnoid, on the cortex or into the lateral 
ventricles. Rarely, an incapsulated abscess may become perma- 
nently encysted. The pus of cerebral abscess is greenish or greenish- 
yellow in color and foetid (Dercum). 

Symptoms. A concise description of the symptoms of abscess 
of the brain is very difficult, on account of the wide variations depend- 
ent on its location, and also the difficulty of isolating it from the affec- 
tions to which it is secondary. 

The onset varies according to the cause, although all cases are 
associated with headache, irritative fever, vomiting, persistent and 
spreading paralysis, convulsions, optic neuritis, mental apathy, de- 
lirium, and coma. 

If following apoplexy, thrombosis, or emboli, there occurs fever 
and delirium, the paralysis remaining and spreading with spasmodic 
contractions of the affected muscles. 

If secondary to a chronic ear disease, there is following sudden stop- 
page of the ear discharge ; severe pain in ear and side of head, accom- 
panied with chill, fever, vomiting, followed in a few days by the disap- 



426 PRACTICE OF MEDICINE. 

pearance of febrile symptoms and the development of a condition of 
stupor, with cerebral symptoms, depending upon the location of the 
abscess. 

Occasionally cases run a chronic course, the onset rather insidious ; 
dull, persistent headache ; changed disposition, peevish, irritable, un- 
reliable, with decline of moral sensibility ; easily fatigued by mental 
work; inability to stand exertion; memory impaired; vertigo; dys- 
pepsia, soon followed by slight palsies, which progressively increase, 
becoming general, with involuntary discharges, death following from 
exhaustion. 

Of the focal symptoms, hemiplegia, of incomplete character, occurs 
in about one-half of all cases of abscess of the brain. A very con- 
stant symptom of diagnostic value, when hemiplegia is very marked, 
is exaggerated knee-jerk with pronounced ankle clonus. 

Diagnosis. A positive diagnosis is only possible by a close study 
of the causes and the clinical history, as the symptoms at times indi- 
cate meningitis and again cerebral tumor. 

Purulent meningitis may follow trauma to the brain or chronic ear 
disease, making the diagnosis impossible. The chief points of dis- 
tinction are : The subacute or chronic course of abscess, slight involve- 
ment of cranial nerves, hemiplegia, and the presence of an active, 
persistent, unilateral ankle clonus and exaggerated knee-jerk on 
paralyzed side. 

Prognosis. The usual termination is in death. The course de- 
pends upon the character and extent of the injury, varying from a 
few days to several months. 

Treatment. Surgical treatment has been attended with marked 
success in some cases of abscess of the brain, the withdrawal of the 
pus being followed by recovery. For traumatic abscess the operation 
of trephining is indicated. Symptomatic treatment for relief of the 
various symptoms as they arise. 



INTRA-CRANIAL TUMOR. 

Synonym. Cerebral tumors. 

Definition. Tumor of the brain is either a growth in the cere- 
bral tissue, on the meninges, or in the vessels ; characterized by 
symptoms of pressure upon the brain structure. 

Causes. Injuries to the head ; syphilis ; changes in the vessels ; 
tubercle and cancer ; heredity. 



DISEASES OF THE CEREBRUM. 427 

Pathological Anatomy. The size of tumors varies, and they 
may become as large as an orange before they will give rise to 
symptoms. 

Tumors of the brain are of various kinds — to wit : vascular tumors 
— aneurisms ; parasitic tumors — cysticercus ; diathetic tumors — tu- 
bercle or syphilis ; accidental tumors — glioma. 

Whatever the character of the growth, it produces irritation of the 
surrounding parts, and by pressure, destruction of the tissues, or 
interferes with the arterial or venous supply. 

Symptoms. Those common to tumors in general are : Headache, 
persistent and increasing in intensity ; defects of vision, even blind- 
ness, due to an optic neuritis, a very constant symptom ; defects of 
hearing, taste, and of speech, the result of paresis of the vocal cords ; 
vertigo, associated with nausea and vomiting ; convulsions, epilepti- 
form in character, usually limited to one side of the body, occurring 
at regular intervals, or confined to the eyeballs (nystagmus) or one 
limb, with no loss of consciousness; palsies, beginning first as strabismus, 
ptosis, and dilatation of the pupil, of the facial muscles, paraplegia 
and general hemiplegia ; defects of sensibility, such as sensations of 
numbness and coldness in the limbs and body. Occasionally dis- 
turbances of equilibrium, manifested by a tendency to go backward 
or turn to the right or left; intellectual faculties well preserved until 
late in the affection, when the memory becomes impaired or lost for 
certain articles, and finally a gradually advancing dementia. 

Diagnosis. Rarely can a positive diagnosis be made. The fol- 
lowing points will aid : Long-continued persistent headache, without 
appreciable cause ; epileptiform convulsions, unilateral, without loss 
of consciousness; difficulty of vision, hearing, and speech, associated 
with nausea and vomiting, and local and general palsies. 

The location of the tumor may be determined by the more or less 
pronounced character of certain symptoms. 

The diagnosis of the character of the growth can only be deter- 
mined by a close study of the history. 

According to Herter, the indications that suggest that the tumor 
is a syphilitic growth are as follows : Syphilitic history ; symptoms 
of irritative disease of cortex rather than destructive evidences of 
rapid growth at the onset, followed by a period of slow progress or 
stationary symptoms; gradual improvement under anti-syphilitic 
treatment; development between twenty and forty- five years of age. 



428 PRACTICE OF MEDICINE. 

Indications suggesting tubercular growth are : Family history of or 
tuberculosis in some other organ of the patient ; rapid development 
of symptoms ; indications of the growth in the cerebellum or in the 
pons; early appearance of the symptoms, especially before the tenth 
year, and history of injury to head. 

Indications suggesting sarcoi7ia or cancer are : The presence of a 
sarcoma elsewhere and rapidly failing health, with cerebral tumor 
symptoms in patient over fifty years. 

Indications suggesting glioma : Sudden loss of consciousness with 
exacerbation of all symptoms in the clinical history of cerebral tumor ; 
cortex irritative symptoms as in syphiloma, developing under fifty 
years of age, and the absence of all evidences of tubercle, syphilis, 
sarcoma, and cancer. 

The focal symptoms of intracranial tumors are so important in diag- 
nosis that the following summary is given of symptoms caused by 
brain tumors : 

Prefrontal region. Mental impairment ; pressure in central region, 
causing aphasia, Jacksonian epilepsy, and disturbances of smell. 

Central region. Motor aphasia, monoplegia, partial anaesthesia, 
Jacksonian epilepsy. 

Posterior parietal region. Word-blindness, homonymous hemi- 
anopsia, disturbed muscular sense. 

Corpus callosum. Progressive hemiplegia. 

Crus cerebri. Crossed paralyses of oculo-motor nerve and limbs. 

Corpora quadrigemina. Oculo-motor paralyses, reeling gait, possi- 
bly blindness and deafness. 

Pons and medulla. Crossed paralysis of face and limbs, or tongue 
and limbs. Other lesions in cranial nerves. 

Cerebellum. Marked cerebellar ataxia, vomiting, convulsions, coma. 

Base, anterior fossa. Mental enfeeblement, and disturbances of 
smell and vision, exophthalmos. 

Base, middle fossa. Impairment of vision ; hemiplegia ; oculo- 
motor disturbances. 

Base, posterior fossa. Trigeminal neuralgia ; neuro-paralytic oph- 
thalmia ; paralysis of the face and tongue ; impaired hearing ; crossed 
paralyses. 

Diagnosis between cerebral tumor and abscess. Both may have 
any or all of the following symptoms : Headache, vomiting, double 
optic neuritis, and mental failure. Tumor has, in addition, marked 



DISEASES OF THE CEREBRUM. 429 

focal symptoms, monoplegia, hemiplegia, paralysis of cranial nerves, 
and marked optic neuritis ; the absence of these favor abscess, or if 
hemiplegia, the ankle clonus and knee-jerk is exaggerated. Fever 
and rigors point to abscess. The causes of abscess are very clear, 
those of tumor often uncertain. 

Prognosis. Unless of syphilitic origin, unfavorable ; but it is to 
be borne in mind that all syphilitic tumors of the brain do not have 
a favorable termination. 

Treatment. Unsatisfactory. Mostly symptomatic. As benefit 
occasionally follows the use of potassii iodidum, gr. xx (1.3 Gm.), three 
times a day, or ext. ergotcs fid., f^ss-j (2-4 Cc), three times a day, 
continued until their physiological effects are produced, these reme- 
dies should be used in all cases, discontinuing them if no benefit fol- 
low. 

The surgical treatment of tumors of the brain was given a great 
impetus from the report of the case operated upon in the practice of 
Hughes-Bennet. The surgical treatment is promising for the future. 



APHASIA. 

Definition. Aphasia is a symptom and not a disease. A loss of 
memory for words. The loss, partial or complete, of the power of 
expression or comprehension of language. 

Amnesic aphasia, or loss of the memory of words by which ideas 
are expressed. 

Ataxic aphasia, the inability to combine the different parts of the 
vocal apparatus for vocal expression, although the memory of words 
still remains, so that the afflicted person can write his ideas intelli- 
gently. 

Agraphia, the inability to recognize and make signs by which 
ideas are communicated in written language. 

Amnesic agraphia, the inability to combine the muscular apparatus 
— "writers' cramp." 

Paraphasia, the mental state in which the wrong words are used 
to express the idea. 

Paragraphia, the state in which wrong or meaningless written signs 
are used to express the idea. 

Pathological Anatomy. The distinction between aphasia and 
aphonia must be clearly determined. 



430 PRACTICE OF MEDICINE. 

Aphasia is not the result of any one specific lesion, but occurs 
during the course of several — to wit : Occlusion of certain cerebral 
vessels ; cerebral hemorrhage ; cerebral abscess or softening ; men- 
ingitis ; tumors; mental or moral causes ; hysteria (?). 

It is now almost definitely determined that lesions of the left 
middle cerebral artery, island of Reil, third frontal convolution, and 
parts of the corpus striatum are associated in the production of 
aphasia. The lesions are usually upon the left side of the brain, 
the aphasia being often associated with right hemiplegia. 

Symptoms. The degree to which articulate language is impaired 
varies from the loss of a few words to complete inability to communi- 
cate ideas. The intellect does not suffer in proportion to the loss of 
words ; for, showing the individual an article, while he may miscall 
it, if you call it by name he will recognize it. This inability to convey 
thoughts is a source of great mental suffering, in some leading to a 
suicidal tendency. 

A strange clinical fact is the strong tendency to profanity shown 
by aphasic patients. 

Diagnosis. Aphonia, or loss of voice, should not be confounded 
with aphasia, or the inability to remember words. 

Paralysis of the tongue, or inability to move this organ, thereby 
interfering with articulate language, should not be confounded with 
aphasia, which, as a rule, is not associated with paralysis of the 
tongue. 

Prognosis. Controlled entirely by the cause. If the result of 
congestion of the brain or a syphilitic tumor, the prognosis is favor- 
able. If associated with hemiplegia, the clot may undergo absorp- 
tion, and recovery follow. If associated with softening of the brain, 
however, the disease grows progressively worse. 

Treatment. Depends upon the cause, which must be energeti- 
cally treated, as the aphasia pursues a course parallel to the associ- 
ated malady. Cases not associated with cerebral softening have 
regained the memory of words by a course of carefully conducted 
speech lessons. 

Cases of aphasia of sudden occurrence are strongly diagnostic of 
injury due to a spicula of bone if a history of a head Wound, or from 
the pressure of a clot, and the operation of trephining may be of 
benefit. 



DISEASES OF THE CEREBRUM. 431 



VERTIGO. 



Synonym. Dizziness. 

Definition. Vertigo, or dizziness, is a subjective state, in which 
the individual affected (subjective vertigo), or the objects about him 
(objective vertigo), seem to be in rapid motion, either of a rotary, 
circular, or to-and-fro character. 

Causes. The etiology of an attack of vertigo depends upon the 
particular variety. 

Ocular vertigo results from the paresis of one or more of the ocular 
muscles, eye-strain, or astigmatism. 

Aural or auditory vertigo, or Meniere 's disease, results from disease 
of the semicircular canals and cochlea. Meniere's disease, properly 
so called, is a sudden severe vertigo, the result of either a hemorrhage 
or a serous or purulent exudation into the semicircular canals. 

Gastric vertigo is the most common variety, and results from either 
stomachic or intestinal dyspepsia, disordered hepatic function, or con- 
stipation. "The mechanism of the vertigo is complex. There are 
two factors : one consists in the toxic effect of the imperfectly oxidized 
materials which accumulate in the blood ; the other is reflex. An 
impression made on the end organs of the pneumogastric in the 
stomach is reflected over the sympathetic ganglia " (Bartholow). 

Nervous vertigo is associated with migraine, sick or nervous head- 
ache, and is also caused by physical or nervous excesses, also by the 
immoderate use of tea, coffee, alcohol, and tobacco. It is also a result 
of many of the organic diseases of the brain. 

Senile vertigo is the result of the disordered cerebral circulation 
resulting from senile changes in the heart and vessels. 

Symptoms. In all varieties of vertigo the symptom of a sensa- 
tion of objects moving aroimd the patient, or the patient moving 
around objects which remain stationary, is present in some degree. 
The attack of giddiness comes on suddenly, with an indistinctness of 
vision and slight confusion of the thoughts. The patient may fall 
unless he grasps something to steady himself. Nausea and vomiting 
and cardiac palpitation with tinnitus aurium are often associated with 
the vertiginous sensations. There is no loss of consciousness. 

In the ocular vertigo the attack is usually the result of reading, 
writing, sewing, or other close application of the eyes, the ordinary 



432 PRACTICE OF MEDICINE. 

symptoms of vertigo being preceded by headache, nausea, specks 
before the eyes, and pain in the eyeballs. 

In Meniere's disease the vertigo is associated with serious tinnitus 
aurium, and the vertiginous sensations are of various forms, such as 
a see-saw movement, a gyratory motion, right or left ; a vertical whirl, 
or a sensation of rising and falling like unto the swell of the ocean. 
The symptoms are of long duration, becoming marked in paroxysms. 
The attack of aggravated vertigo is so sudden and overwhelming at 
times that the person is suddenly thrown to the ground as if struck 
with a blow, and is associated with nausea and vomiting. As the 
condition continues, the character of the individual changes, becoming 
morose, irritable, and suspicious. 

Not all cases of Meniere's disease become permanent, but it may 
occur in isolated attacks, the interval being free from all sensa- 
tions. 

Gastric vertigo is by far the most frequent variety. Persons subject 
to vertigo of this kind live in constant dread of cerebral disease, which 
fear frequently results in true melancholia. 

The vertiginous sensations usually occur during the course of well- 
marked and long-standing stomach and intestinal disorders, such as 
pain or oppression after meals, nausea, pyrosis, heartburn, frequent 
eructations, and constipation or, rarely, diarrhoea. The abdomen is 
often distended with flatus. Great pain in the nucha is a very frequent 
occurrence. The attack may be associated with either hyperemia or 
anaemia of the brain. The symptoms are not constant, but recur at 
intervals, sometimes remote, at others very close to each other. 

In nervous vertigo the vertiginous symptoms are usually associated 
with more or less irritability of temper, restlessness, and insomnia. 
The onset is sudden, after some one of the etiological factors. In 
megrim there are headache, nausea, and vomiting. This form of ver- 
tigo often precedes or replaces the epileptic convulsion. And it also 
often precedes softening of the brain. 

In senile vertigo the vertiginous symptoms are the result of anaemia 
of the brain. The attacks are developed by any exertion, often by 
merely assuming the erect posture. There is a swimming sensation 
in the head, darkness falls on the eyes, with a sensation of chilliness 
and prostration. 

Diagnosis. The diagnosis of the various forms of vertigo can 
only be determined after a close study of the history and course of 



DISEASES OF THE CEREBRUM. 433 

the attack. The existence of organic cerebral disease must always be 
kept in mind in solving any case. 

Prognosis. This will'be influenced by the variety of the vertigo. 
The prognosis is favorable in ocular and gastric vertigo. Unless the 
result of organic disease, the prognosis is good in nervous vertigo. 
In auricular vertigo the prognosis is fair, but in genuine Meniere's 
disease the prognosis is unfavorable, as it is also in senile vertigo. 

Treatment. For ocular vertigo, rest for the eyes and properly 
adjusted glasses. 

For cases of Meniere's disease, rest in the recumbent position and 
the use of full doses of quinines sulphas, gr. x-xv (0.6-1 Gm.), daily 
until cinchonism occur, then omiting the drug until these effects dis- 
appear, and if no improvement is observed, begin another course, 
and so on as suggested by Charcot. 

For gastric vertigo a careful regulation of the diet. At the begin- 
ning of the treatment it is often of great advantage to place the 
patient on an exclusively milk diet, gradually widening the variety 
as improvement occurs. In these cases a course of arsenicum is 
often serviceable. If the digestion be torpid, the use of tinctura 
nucis votnicce is indicated. If the bowels are constipated, benefit is 
obtained from exir actum case arcs sagrades fluidum. 

R. Ext. cascarae sagr. fld., . . . . f,^j 30. Cc. 

Glycerini, f^j 30. Cc. 

Tinct. card, comp., f,l ss r 5- Cc. 

Aquae men thse pip., f^ ss r 5- Cc. M. 

SlG. — One teaspoonful three times daily, well diluted. 

For nervous vertigo the removal of the exciting cause and the use 
of such remedies zsferrum, quinina, and strychnina, either alone or 
variously combined. 

For senile vertigo, a highly nutritious but easily digested diet, the 
use of a good spiritus frumenti and a course of hydrargyri chloridum 
corrosivum, or arsenicum with tinctura nucis vomicce, or a long course 
of spiritus glonoini. Prevent flatulency and constipation. 

In all varieties of vertigo the habits of the patient must be most 
abstemious, excluding tobacco, tea, coffee, highly seasoned foods, 
malt liquors, and alcohol, unless particularly indicated. 



37 



434 PRACTICE OF MEDICINE. 



MIGRAINE. 



Synonyms. Megrim ; hemicrania ; sick headache ; bilious head- 
ache; blind headache. 

Definition. A unilateral paroxysmal pain in the-head, periodical, 
accompanied by nausea, often vomiting, intolerance of light and 
sound and incapability of mental exertion, the brain for the time 
being temporarily prostrated and disturbed. 

Causes. In the majority of patients the nervous predisposition 
to migraine is inherited, but whether inherited or acquired, it com- 
monly develops about puberty. It is more common in women than 
in men. 

Among the many exciting causes are disturbances of digestion, 
irritation of the ovaries or uterus, worry, exacting mental labor, sex- 
ual excesses and insufficient sleep, or eye strain. The causes of 
many attacks, however, are wrapped in mystery, as with the best of 
care the attacks seem to have a periodical course. 

Symptoms. Attacks of migraine occur in irregular paroxysms, 
the intervals between being free from pain or nervous disturb- 
ance. 

For a day or two preceding the paroxysm it will be ascertained 
that there was a feeling of fatigue or mental depression without 
apparent cause, heaviness over the eyes, with some flatulency and 
indigestion. 

The attack proper is ushered in by chilliness, yawning, nausea, often 
vomiting, and general muscular soreness, with intolerance of light, 
flashes before the eyes, and often phantasms, and noises in the ears 
with incapability for mental exertion, vertigo, and pain of a sharp, 
shooting character, of great intensity and persistency, localized most 
frequently in either the frontal, temporal, or occipital regions of the 
left side ; at the same time there is tenderness over the whole side 
of the head. Rarely the pain is felt on the right side, and still more 
rarely on both sides at the same time. The nausea and other diges- 
tive symptoms may follow the onset of the pain instead of preceding 
it. 

There is more or less disturbance of the circulation, temperature, 
and secretions of the painful parts. At times there is a marked con- 
traction of the vessels, with the face pale, the eyes shrunken, and the 



DISEASES OF THE CEREBRUM. 435 

pupils dilated ; again, the vessels may be dilated, when the face is 
flushed, the conjunctivae injected, and the pupils contracted. 

The urine before, during, and after a paroxysm is concentrated, and 
it may be that the excretion of uric acid is associated with the etiology 
of migraine. 

Motion, sound, and light aggravate the acute suffering. 

The attack may continue with more or less intensity from a few 
hours to two or three days, the average duration being twenty-four 
hours. 

Diagnosis. The symptoms are so characteristic that an error 
seems impossible. It may, however, be confounded with anaemic 
headache, hyperaemic headache, dyspeptic or bilious headache, and 
neuralgic or rheumatic headache. The pains of organic brain disease 
must be excluded. 

Prognosis. While few cases of true migraine are permanently 
cured, the affection is free from danger to life. In a fair number of 
cases the susceptibility to attacks declines as the person advances in 
years, it being rarely seen after fifty years. 

" Cases of migraine of the ophthalmic variety appear to be not 
rarely followed by general paralysis of the insane" (Herter). 

Treatment. To abort an attack of migraine or dispel a paroxysm 
after its onset, rest in bed in a quiet, darkened room, with abstinence 
from food, and any one or two of four remedies are almost infallible 
— one is a hypodermic injection of morphines sulphas, gr. ]i (0.016 
Gm.), with atropines sulphas, gr. T ^ (0.00054 Gm.), or aniipyriiu, gr. 
xx (1.3 Gm.), repeated in an hour or two ; or phenacetin, gr. x (0.6 
Gm.), repeated in an hour or two. An excellent combination for the 
relief of the paroxysm is : 

R. Phenacetin, gr. xx 1. 3 Gm. 

Caffeina citrata, . . gr. v .3 Gm. 

Camphorse monobrom., gr. xx 1.3 Gm. M. 

Ft. capsule No. x. 

SiG. — One every two hours until relief. 

In many attacks extraction cannabis indices fluidum, rr^ij-iij 
(0.12-0.2 Cc), every half hour or hour for a number of doses, alone 
or combined with extractum gelsemii fluidum, in the same dose, 
is curative. 

A combination for attacks associated with contraction of the vessels 
is — 



436 PRACTICE OF MEDICINE. 

R. Potassii bromid., . . . . . . . gr. xxx 2. Gm. 

Morphinae sulph. , g r - X - OI ^ Gm. 

vel 

Codeince sulph., gr. j .065 Gm. 

vel 

Tr. opii deodorat. , rt^xxx 2. Cc. 

Aquae menth. pip., . . . . adf^ss ad 15. Cc. M. 

Sig. — Repeated p. r. n. 

The local use of menthol pencils eases the pain, and the inhalation 
of spiritus camphorae is agreeable. 

In the intervals between the paroxysms employ measures to im- 
prove the general system, and to overcome as far as possible any 
of the etiological factors. For this purpose extractum cannabis 
indices, gr. %. (0.016 Gm.), three times daily for several months, is 
highly recommended. 

" If the disposition to the malady is inherited, the prophylaxis is 
very important, and should include diet, exercise, clothing, and the 
avoidance of all those conditions which tend to develop an abnormal 
excitability of the nervous system. The best results have been ob- 
tained from galvanization of the superior ganglia of the sympathetic ; 
the positive pole over the ganglion and the negative on the epigas- 
trium in the tetanic (contraction of vessels) form, and the poles 
reversed in the paralytic (dilatation of vessels) form " (Bartholow). 



ALCOHOLISM. 

Varieties. Acute alcoholism ; chronic alcoholism. 

Synonyms. Acute variety ■, temulentia ; mania a-potu. 

Chronic variety, delirium tremens; dipsomania, or oinomania. 

It would hardly be correct to consider these terms interchangeable ; 
they are rather names applied to various conditions due to acute or 
chronic alcoholic poisoning. 

Definition. Alcoholism is the term used to designate the physi- 
cal and mental phenomena induced by the abuse of alcohol. Alcohol 
is a poison, but becomes a much more dangerous one when asso- 
ciated with the various toxic products which are added to flavor it. 

Temulentia, meaning drunkenness, or alcoholic intoxication ; 
mania-a-potu is an acute mental derangement, occurring in those of 
strong neurotic tendencies ; delirium tremens is an attack of delirium 



DISEASES OF THE CEREBRUM. -437 

associated with tremors in persons with the numerous changes 
resulting from chronic alcoholism. Delirium tremens frequently 
results in alcoholics having one of the forms of nephritis, preventing 
the elimination of some poison developed from the ingested alcohol. 
Dipsoinania, or oinomania, an alcoholic insanity in which an indi- 
vidual at longer or shorter intervals has paroxysms of alcoholic 
desires, between which he neither wishes nor craves alcohol. 

Causes. Predisposing causes are influences arising from unfavor- 
able moral, social, and personal conditions. Heredity. 

Exciting causes are the immoderate use of alcoholic beverages, of 
which there are three groups : I, spirits, or distilled liquors ; 2, wines, 
or fermented liquors, and 3, malt liquors. 

Pathological Anatomy. Acute Alcoholism. The brain is the 
seat of an active hyperemia ; the mucous membrane of the stomach 
and duodenum is markedly injected and covered with a ropy mucus 
slightly tinged with blood, and the gastric juice is altered in quality 
and quantity. The kidneys are also the seat of an active hypersemia. 

Chronic Alcoholism. In this condition there are no organs or 
tissues which do not present morbid changes. The gastro-intestinal 
mucous membrane presents the changes of chronic catarrhal in- 
flammation ; the liver, the first organ to receive the poison after 
the stomach, presents the changes of congestion, cirrhosis, or fatty 
degeneration ; the kidneys show chronic congestion and often 
the changes incident to chronic interstitial nephritis. The post- 
mortem results found in twenty-five cases of delirium tremens dying 
in the Philadelphia Hospital showed fourteen with the changes of 
interstitial nephritis, eight with chronic parenchymatous nephritis, 
and three with fatty kidney ; all showed chronic gastric catarrh and 
changes in the myocardium and the arteries of the heart, brain, and 
the aorta. The muscular structure of the heart may undergo fatty 
degeneration and the vessels the senile changes of the aged. The 
brain structure presents the changes of sclerosis in various stages, and 
there may be chronic meningitis and pachymeningitis with hsematoma. 
The nerves are altered, atrophied, and hardened, and the neuroglia, 
vessels, and ganglion cells of the spinal cord show similar changes. 

Symptoms. Acute alcoholis})!, resulting from the use of a large 
quantity of alcoholic fluid, occurs with symptoms of mild intoxica- 
tion to drunkenness passing to acute delirium and acute coma. The 
condition begins with a period of exhilaration, passing to semi- 



438 PRACTICE OF MEDICINE. 

deliriwn and ending in an acute coma, when the breathing is ster- 
torous, the face bloated and congested, the lips swollen and purplish, 
the pupils contracted or dilated, the pulse feeble and slow, the skin 
cold and clammy, the temperature depressed, and frequently co7itrol of 
sphincters lost. An individual so affected is said to be " dead drunk " 

Cases of ordinary drunkenness do not often pass beyond the stage 
of exhilaration, ending in a mild coma or sleep. 

Mania-a-potu, or acute alcoholic delirium, is the direct result of 
alcoholic excess in those engaged in a sudden debauch, or who 
have drunk alcoholic beverages very "hard" for a comparatively 
short period. The individuals grow more and more excitable, 
lose all desire for food, are unable to sleep, become the prey of 
horrible hallucinations, — "the horrors," — finally terminating in mania 
which resembles delirium tremens in all save the tremor, which is 
absent. 

Delirium Tremens. In the majority of instances delirium results 
from a prolonged debauch, in an old drinker, with abstinence from 
proper food. It begins by an increased tremor, insomnia, irritable, 
excited manner, followed by the characteristic hallucinations and 
illusions, during which snakes and other forms of repulsive reptiles are 
seen, causing the most intense horror and abject fear; it is a busy 
delirium, the patient unable to remain quiet. There also occur illu- 
sions of smell and hearing. This marked excitement is followed by 
great depression, the skin is cold and clammy, the pulse feeble, the 
muscular system weak, the mind in a condition of coma-vigil, and 
if continued, a febrile condition, typhoid in character, with stupor or 
coma, develops. Urczmic symptoms frequently complicate the con- 
dition, the temperature suddenly bounding to 103 F., to 104 F., or 
105 F., with albumin and casts in the scanty urine. 

The ordinary duration of an attack of delirium tremens is about 
two weeks in those who recover, although death may occur at any 
time from cardiac failure, uraemia, or alcoholic pneumonia. Indeed, 
patients sometimes die suddenly in whom improvement had begun. 
Convalescence dates from the beginning of refreshing sleep, the 
patient awakening with a clear mind and desire for food. Should the 
delirium subside, but the patient continue to mutter and pick at the 
bed-clothing, the tongue become dry and cracked, and the regurgita- 
tion of dark brownish and bilious matter occur, the condition is 
critical and an early fatal termination may be expected. 






DISEASES OF THE CEREBRUM. 439 

Dipsomania, or oinomania, is the inherited or acquired mental con- 
dition which craves the drinking of intoxicating liquors. This is a 
true mental disease. It manifests itself in periodical attacks of exces- 
sive indulgence in alcoholic drinking, or this symptom of the sad 
disease may be replaced by other irresistible desires of an impulsive 
kind, such as lead to the commission and repetition of various crimes, 
the gratification of other depraved appetites, robbery, or even homi- 
cide. Imbecility and dementia frequently result. 

The paroxysms at first occur at long intervals, but gradually the 
intervals become shorter and shorter until the individual entirely sur- 
renders himself to alcoholic and other excesses. 

Chronic Alcoholism. The condition to which this term has been 
.given is truly a disease. It is the result of the continued use of alco- 
holic beverages until one or more of the morbid organic changes 
have occurred. These persons are markedly dyspeptic, with coated 
tongue, fetid breath, and early morning vomiting, straining, or retch- 
ing, attended with much distress. There is a gradually developing 
muscular tremor, progressing to the ataxic gait. Insomnia or restless 
sleep is frequent. The face may either become pallid, flabby, and 
bloated, with an imbecilic expression, or swollen, rough, and dusky, 
with great bladders under the eyes, with yellow injected conjunc- 
tivae. There is headache, vertigo, and attacks of hallucinations ; 
the memory grows weaker, the judgment less accurate, the moral 
sense blunted, and the will power weak and erratic. These and 
many other symptoms add to the distress of the individual, which 
he attempts to overcome by the use of more and more of the poison. 

Diagnosis. Profound drunkenness, or alcoholic coma, may and 
often is confounded with apoplectic and ursemic coma. Von Wede- 
kind suggests the following method for diagnosing drunkenness: 
" By simply pressing on the supraorbital notches with a steadily 
increasing force you may, with certainty of success, bring an un- 
conscious alcoholic to his senses, and thus differentiate between alco- 
holic and other comas." 

The symptoms of chronic alcoholism often bear a close resem- 
blance to the following maladies: General paralysis, disseminated 
sclerosis, paralysis agitans, locomotor ataxia, cerebral and spinal 
softening, epilepsy, dementia chronica, and nervous dyspepsia. 

In individuals whose habits are secret the question of diagnosis is 
attended with considerable difficulty. Anstie lays much stress upon 



440 PRACTICE OF MEDICINE. 

the importance of the following four points, diagnostic of chronic 
alcoholism : insomnia, morning vomiting, muscular tremor, and cause- 
less mental restlessness. 

Prognosis. In acute alcoholism the prognosis is good if the 
patient is manageable. 

In chronic alcoholism the organic changes, the direct result of the 
alcoholic habit, tend to shorten life by the production of fatty heart, 
Bright's disease, insanity, impotence, epilepsy, melancholia, and 
organic brain diseases. The danger in delirium tremens is heart 
failure or deepening coma. The association of chronic nephritis with 
delirium tremens, perhaps its cause, must always be taken into account 
in determining a prognosis. Acute lobar pneumonia is a very fatal 
complication in all forms of alcoholism. 

Treatment. In deciding upon a plan of medication for any of the 
varieties of alcoholism, the condition of the kidneys, heart, and vessels 
must be considered. The treatment of a case of ordinary drunken- 
ness requires little consideration, as the rapid elimination of the 
alcohol soon occurs if its ingestion be stopped. Liquor ammonii 
acetatis in large, frequently repeated doses, assists the elimination of 
the poison. 

For mania-a potu the immediate and complete withholding of alco- 
holic beverages is essential for its successful treatment. If the stom- 
ach will tolerate food, — and usually it will, — milk diluted with liquor 
calcis, or Seltzer water, or hot beef tea strongly seasoned with capsi- 
cum, should be administered every hour or two in small amounts. 

The appetite is stimulated by the use of a combination like — 

R . Tinct. nucis vomicce, f ^ iv 15. Cc. 

Tinct. capsici, f,^i y I 5- Cc. 

Tinct. cinchonoe comp. , . . . . f ^ ij 60. Cc. M. 

Sig. — One teaspoonful, diluted, every two or three hours. 

This stomachic stimulant may be alternated with spiritus ammonicz 
aromaticus, iZ) (4 Cc), given in hot milk, with advantage to the heart 
and nervous irritability. The bowels should be moved at once by 
the administration of an enema: 

]£. Magnesii sulph., % ij 60. Gm. 

Glycerini , , . . . f 5j 30. Cc. 

Aquae bul., f 3 iv 120. Cc. 



DISEASES OF THE CEREBRUM. 441 

and the kidneys stimulated by full doses of spiritus cetheris nitrosi if 
the patient will swallow, and, if not, by the hypodermic use of caffeines 
citrata. The restlessness, insomnia, delirium, and visual and auditory 
hallucinations are usually controlled with chloral, and, on account of 
the gastric torpor and catarrh interfering with the prompt absorption 
of medicaments, is best given by the bowel : 

R. Chloral, gr. xx-xxx 1. 3-2 Gm. 

Infus. digitalis, 1%) 30. Cc. 

Repeated in two hours, in milk. 

If enema cannot be used, chloral or trional, gr. xxx (2 Gm.), may be 
given by mouth, or resort may be had to hypodermic medication if 
there is urgency, using tnorphince sulphas, gr. %-% (0.016-0.022 Gm.), 
combined with atropines sulphas, gr. -^q (0.00065 Gm.), or hyoscina 
hydrobromas, gr. y^ (0.00065 Gm.). If the attack be associated with 
symptoms of cardiac depression, use brisk friction, hot alcohol and 
water sponging, artificial warmth, stimulating enemata, and the hypo- 
dermic administration of strychnines sulphas, gr. ^V~^V (°- o0 3~ 
0.002 Gm.), repeated, or caffeina citrata, gr. iij (0.2 Gm.), or digitalis 
" If chloral be inadmissible by reason of weakness of the circulation, 
paraldehydum may be substituted, in doses of from f^ss-j (2-4 
Cc), repeated at intervals of from one to two hours until quietude is 
produced " (J. C. Wilson). 

If one or two medicinal doses of the selected sedative drug does 
not produce quiet and sleep, be most cautious in repeating, remem- 
bering that the patient is suffering from the depressing effects of a 
cardiac and nervous poison, which is best combated by eliminating 
action on skin, bowels, and kidneys, and the administration of food. 

An attack of acute alcoholism, or mania-a-potu, may often be 
aborted with trio?tal, gr. xxx (2 Gm.), repeated in two hours, or 
chloralamid, gr. xxx-xl (2-2.6 Gm.), repeated. Excellent and prompt 
results follow the use of a hot-air bath until profuse sweating. 

For the collapse following a lethal dose of alcohol, the stomach 
should be immediately emptied by emetics or the stomach tube or 
pump and the organ washed out with warm water or coffee, the 
patient placed in the recumbent position, and surrounded with arti- 
ficial warmth, hot frictions to the lower extremities, the use of artificial 
respiration or the use of faradism to the thorax, inhalations of 
ammonia, hypodermic injections of strychnina; sulphas, spiritus 
38 



442 PRACTICE OF MEDICINE. 

glonoini, digitalis, slrophanthus, or atropines sulphas. " The flagging 
heart may be stimulated by occasionally tapping the praecordia with 
a hot spoon — Corrigan's hammer" (J. C. Wilson). 

Delirium Tremens. — The patient should be isolated, have a skillful, 
sensible nurse, have the quantity of alcohol entirely withdrawn, or 
greatly reduced, have the stomach washed out daily, be supplied with 
easily digested nutritious diet, and action on the skin, kidneys, and 
bowels, with remedies to combat the excited nervous system. For 
this latter purpose no one combination is comparable with hypo- 
dermic injections of morphines sulphas, gr. % (0.016 Gm.), with 
atropines sulphas, gr. y^ (0.00065 Gm.), or hyoscines hydrobromas, 
gr. ^q (0.00065 Gm.), repeated, or the use of chloral or trional by the 
bowel or by the stomach if the patient can or will swallow, or the 
stomach is not too irritable : 

R. Chloral, ^iv 15. Gm. 

Tr. capsici, f 3 ij 8. Cc. 

Aquae nienth. pip., . q. s. ad f Jvj ad 180. Cc. 

Sig. — Tablespoonful every .two hours until sleep, alternated with a cup 
of hot beef-tea, to which has been added a bolus of capsicum, gr. xx 
(1.3 Gm.). 

Care is necessary that a condition of coma be not produced by the 
remedies mentioned, never giving more than two doses within six 
hours, but pushing hot liquid diet and atropine sulphas, gr. g 1 ^ (0.001 
Gm.), with strychnines nitras, gr. -^ (0.002 G:n.), by the hypodermic 
method, as experience has proven that these drugs given three times 
daily in reducing doses are the physiological antidote to the alcoholic 
toxin. 

For depression and cardiac weakness, the internal use of any one 
of the following drugs is serviceable : Strychnines sulphas, caffeine 
citrata, spiritus chloroformi, ammonii carbonas, tinctura sirophanthus, 
or digitalis. 

For the stomach atony use the nux and capsicum mixture men- 
tioned above and washing out the stomach every day or two. 

Other nervous sedatives recommended are paraldehydum, chlor- 
alamid, and the bromides. 

Strict attention must be given to the skin, bowels, and kidneys. If 
the heart is not depressed, the cautious use of the hot-air bath or hypo- 
dermic injections of pilocarpine hydrochloras, gr. % (0.02 Gm.), 
repeated at the onset of the mania. 



DISEASES OF THE CEREBRUM. 443 

Chronic Alcoholism. — The combine of symptoms termed chronic 
alcoholism are the direct result of the continuous action of a toxic 
principle, and no success of even a temporary kind can be expected 
unless the poison be withdrawn. The rapidity with which this can be 
accomplished is a question for the skill, judgment, and experience of 
the physician to determine ; the chief obstacle to its success will be 
found moral rather than physical. Next to the disuse of alcohol is 
the question of diet. Progress will be made as the appetite and 
digestion improve, and great attention should be given to these. The 
general health will also be benefited by fresh air, exercise, mental 
occupation, and cold or tepid sponging and an occasional hot bath at 
bedtime. For the combination of symptoms of spirit-craving, morn- 
ing vomiting, muscular tremor, mental restlessness, and insomnia, no 
drug is comparable with strychnines nitras, either hypodermically 
twice daily, or, what is preferable, by the stomach to secure its local 
action on the mucous membrane. If the insomnia be persistent in 
spite of the foregoing treatment, the temporary use may be made of 
such remedies as chloral, morphince sulphas, paraldehydum, or irional. 
In many cases it is desirable, for its mental effect, if no other, 
administer what the patient terms a substitute for his alcoholic 
beverages. The following is a good combination for that purpose : 

$ . Tincturse nucis vomicae, . . . fjfss 15. Cc. 

Tincture capsici, f^ ss 15. Cc. 

Ext lupulini fid , f ^ iij 90. Cc. 

Inf gent co., f^ij 60. Cc. M. 

Sig. — Dessertspoonful three or four times daily, well diluted. 

For the anaemia, loss of strength, and mental debility, benefit may 
follow the use of syrupus hypophosphitis cum strycJmince. 

Dipsomania. — The management of these cases is much the same 
as has already been mentioned for chronic alcoholism, although the 
strychnines sulphas treatment should be given the preference. 



HEAT STROKE. 

Synonyms. Insolation ; sunstroke ; thermic fever ; coup-de- 
soleil; heat exhaustion. 

Definition. A depression of the vital powers, the result of 



444 PRACTICE OF MEDICINE. 

exposure to excessive heat. The condition manifests itself as acute 
meningitis (rare), heat exhaustion (common), and as true sun- 
stroke. 

Causes. Exposure to the influence of excessive heat, either to the 
direct rays of the sun or artificial heat in confined quarters, or diffused 
atmospheric heat without proper ventilation. 

Among the predisposing causes which act by lessening the power 
of the system to resist the heat, are great bodily fatigue, overcrowd- 
ing, and intemperance. 

Pathological Anatomy. The action of the heat upon the 
system is so sudden, and the malady so rapid in its course, that 
structural changes have not developed. The left ventricle is firmly 
contracted (Wood). The right heart and vessels are gorged with 
dark fluid blood. All the tissues and organs of the body are in a 
state of great venous congestion. The blood is dark, thin, and 
either but feebly alkaline or decidedly acid, and its power of co- 
agulability is destroyed. The post- mortem rigidity is early and 
marked. 

Symptoms. Depending upon the variety. 

Acute meningitis, the result of exposure to heat, has symptoms 
similar to those due to other causes. 

Heat exhaustion develops with a rapid feeling of weakness and 
prostration, the surface cool, the face pale, the voice weak, the pulse 
rapid and feeble, the respiration increased, the vision growing dim 
and indistinct, noises develop in the ears, the individual, overcome, 
becoming partially or completely unconscious. In some cases the 
attack of prostration is sudden, the person falling unconscious, with 
perhaps convulsio?is or tre?nors, and shrunken features. 

Sunstroke. The symptoms developing suddenly, with or without 
prodromata, are insensibility, with or without delirium or convulsions 
ox paralysis, the surface flushed and hot, the conjunctiva injected, and 
breathing either rapid and shallow or labored and stertorous, thepulse 
quick and either bounding or weak, and the temperature in the axilla 
ranging from 105 to 108 , to no , with suppression of all glandular 
action. Death occurring, the result of asphyxia, or from a slow 
failure of respiration and cardiac action. 

Diagnosis. It is of great importance, therapeutically, to distin- 
guish at once between attacks of sunstroke and heat exhaustion. 
Cases of sunstroke are to be differentiated from cerebral hemorrhage 



DISEASES OF THE CEREBRUM. 445 

and alcoholic insensibility, for which purpose the clinical thermometer 
is indispensable. 

Prognosis. Attacks of heat exhaustion, if properly and promptly 
treated, favorable. The prognosis of sunstroke, or heat-fever, is 
unfavorable in the majority of cases, death resulting in from half an 
hour to several hours. Unfavorable indications are, increased tem- 
perature, cardiac failure, convulsions, absent reflexes, followed by 
complete muscular relaxation. 

Favorable indications are, decline in surface heat and axillary or 
rectal temperature, stronger pulse, increased depth of respirations, 
restored reflexes, and return of consciousness. 

Sequelse. If recovery follow either variety, any one of the fol- 
lowing conditions may result : headache, vertigo, insomnia, epilepsy, 
mental enfeeblement, and monoplegia, paraplegia, or hemiplegia. 

Treatment. Cases of heat exhaustion are successfully treated by 
placing the patient in the recumbent position, with the head low and 
the use of stimulants. If able to swallow, administer at once spiritus 
vini gallici, ^ss-j (15-30 Cc), with tinciura opii deodorata, Tr^xv-xxx 
(1-2 Cc), to be repeated p. r. n. ; and spiritus ai7irnonics aromaticus, 
fo\j (4 Cc), in hot water or milk every half hour. If he be unable 
to swallow, the remedies may be thrown into the rectum, or spiritus 
frumenti, strychnines sulphas \ and tinctura digitalis can be used hypo- 
dermically. As convalescence occurs, tonic doses of quinines hydro- 
chloras and strychnines sulphas should be prescribed. 

For sunstroke, the indications for treatment are the very opposite. 
The patient is in imminent danger from the extraordinary temperature, 
and measures to reduce it must at once be instituted. Of these none 
give such excellent results as rubbing with ice, or the cold bath or cold 
pack, and cold affusions, cold eneniata, and the hypodermic use of 
quinines sulphas, or aniipyrin. The tendency to subsequent rise of 
temperature is met by wrapping the patient in a wet sheet, or the 
repetition of the hypodermics mentioned if consciousness has not 
been regained, when they can be given by the mouth. If convulsions 
and restlessness occur, the hypodermic use of morphines sulphas, gr. 
%-% (0.016-0032 Gm.), cautiously repeated, is successful, or chloral 
and the bromides by the rectum. If symptoms of depression occur, 
the stomachic, rectal, or hypodermic administration of stimulants is 
indicated, and strychnines sulphas, gr. -£% (0.0025 Gm.) repeated half 
hourly by the hypodermic method. 



446 PRACTICE OF MEDICINE. 

For convalescence, use quinituz hydrochloras, strychnine? sulphas 
or ferrum . 

ACUTE HYDROCEPHALUS. 

Synonyms. Acquired hydrocephalus; serous apoplexy. 

Definition. Strictly speaking, hydrocephalus signifies water in 
the brain ; but it is here restricted to the presence of a serous fluid in 
the arachnoid spaces, in the pia mater, in the ventricles, and in the 
brain substance (oedema) ; characterized by the more or less sudden 
development of cerebral excitation, followed by depression and 
usually death. 

Causes. Most common between the ages of one and five, 
although it may occur at any age. " The predominance of the nerv- 
ous system in the bodily conformation" is a strong predisposing 
cause. Among the exciting causes are unfavorable hygienic con- 
ditions, dentition, eruptive fevers, blows on the head, mechanical 
causes preventing the return of the blood from the venae Galeni and 
the right sinus, compression of the jugular vein, diseases of the right 
heart, and Bright's disease. 

Pathological Anatomy. The effusion may be limited to the 
ventricles, although there is usually considerable distention of the 
subarachnoid spaces and oedema of the pia mater and neighboring 
portions of the brain, whence results more or less softening, especially 
around the ventricles. The choroid plexus is hyperaemic, and may 
be the seat of minute extravasations. 

Symptoms. There are three varieties of acute hydrocephalus 
with characteristic symptoms, to wit : comatose, convulsive, and the 
ordinary. 

Comatose variety, known also as "serous apoplexy," begins 
abruptly with the phenomena of apoplexy, the result of the sudden 
effusion. The pressure is usually so great on the medulla oblongata 
that it ceases to functionate, death resulting in a few hours, rarely 
lasting several clays. 

Convulsive variety, the result of Bright's disease or a general 
dropsy, is ushered in with headache, nausea, and vomiting, followed 
in a day or two with convulsions, passing into coma, which usually 
terminates fatally, although rarely a remission may precede death for 
a day or two. 



DISEASES OF THE CEREBRUM. 447 

Ordinary variety, the most common in children, begins with fever- 
ishness, headache, vertigo, photophobia, restlessness, nocturnal deli- 
rium, insomnia, twitching, and spasmodic contractions of the muscles 
and great hyperesthesia of the skin. Such symptoms continue for 
several days, when convulsions occur, followed by death, or a con- 
tinuance of the symptoms, followed by rigidity, stupor, and death. 

Prognosis. Unfavorable. 

Treatment. An attempt may be made to remove the fluid by 
diuretics and full doses of potassii iodidum. 



CONGENITAL HYDROCEPHALUS. 

Synonym. Chronic hydrocephalus (?). 

Definition. An excessive accumulation of the cerebro-spinal 
fluid — a cerebral dropsy — in the ventricles — internal hydrocephalus, 
or in the meshes of the pia arachnoid — external hydrocephalus, or in 
both — mixed hydrocephalus ; characterized by enlargement of the 
head and more or less pronounced nervous phenomena. 

A disease of infants or very young children. 

Causes. Imperfect or arrested development of the brain or its 
membranes. Occurs in the offspring of tubercular, scrofulous, or 
syphilitic parents. Inflammatory changes in the ventricles and 
ependyma. 

Pathological Anatomy. Enlargement of the head is the chief 
external pathological condition, although there is no constant ratio 
between the size of the head and the amount of fluid, the quantity 
varying from an ounce to a pint or more. The liquid is transparent, 
of a straw color, containing a small amount of albumin and chloride 
of sodium. 

If the quantity of fluid be small, the ventricles are simply distended ; 
if the amount be large, the optic thalami and corpus striatum are 
depressed and flattened, the roof of the ventricles thinned, and the 
foramen of Monro is greatly enlarged. • The enlargement of the head 
may occur before birth and impede or prevent natural delivery, or the 
head may be normal at birth and increase afterward. As enlargement 
progresses, the bones are so thinned as to be translucent, the fonta- 
nelles and sutures are widened, the lateral portions of the cranium 
project, the forehead bulges out over the eyes, and the orbital plates 



448 PRACTICE OF MEDICINE. 

are depressed, forcing the eyes outward and downward, producing a 
variety of exophthalmos ; the head has an irregular, triangular shape, 
the base of the triangle being the top of the head. The scalp being 
stretched by the pressure within, becomes tense and thin, and but 
scantily covered with hair ; the veins which ramify in it are unusually 
prominent and large, and the entire head is elastic on pressure, from 
the amount of liquid beneath. 

Hilton, in Rest and Pain, says: " In almost every case of internal 
hydrocephalus which I have examined after death I found that this 
cerebro-spinal opening (between the fourth ventricle and the spinal 
canal) was so completely closed that no cerebro-spinal fluid could 
escape from the interior of the brain ; and, as the fluid was being 
constantly secreted, it necessarily accumulated there, and the occlu- 
sion formed, to my mind, the essential pathological element of internal 
hydrocephalus." 

Symptoms. The increased size of the head, with the emaciated 
condition of the child, who seemingly eats well, is what first attracts 
the attention. The head appears too heavy ; the eyes are prominent 
and have a downward direction ; the face is devoid of expression, old 
and wrinkled, the voice feeble ; the mental development is not in 
keeping with the age. When the period for standing or walking 
arrives, the power is found wanting. The further history is but a con- 
tinuation and exaggeration of this, until convulsions occur, which 
sooner or later terminate fatally. 

The course of congenital hydrocephalus is usually slow, but pro- 
gressively worse. The majority terminate within the first year ; cases 
are recorded, however, of ten and fifteen years' duration. 

Diagnosis. In rachitis the volume of the head is increased, due, 
in part, at least, to a deposit of calcareous matter on the exterior of 
the cranial bones. Rachitis may be mistaken for hydrocephalus in 
cases in which the amount of liquid is small. The differential diagnosis 
is based on the shape of the head — round in rachitis, square or tri- 
angular or with prominences in hydrocephalus, with the persistent 
downward direction of the eyes and the elasticity of the head on 
pressure. 

Prognosis. Unfavorable. Arrest of progress and even cures 
have been reported. Spontaneous cures have been reported fol- 
lowing the accidental discharge of the fluid. But such reports are 
exceptional. 



DISEASES OF THE SPINAL CORD. 449 

Treatment. The use of the finest aspirator needle to evacuate 
the fluid is fully justifiable. The proper situation for the puncture is 
the coronal suture, about an inch or an inch and a half from the 
anterior fontanelle. Firm but gentle compression of the cranium 
with adhesive strips should be made during the escape of the fluid 
and afterward. A few ounces of fluid only should be withdrawn at a 
time. The internal use of potassii iodidum is recommended. 

All measures which tend to promote the constructive metamor- 
phosis are to be employed. 



DISEASES OF THE SPINAL CORD. 



SPINAL HYPEREMIA. 

Synonyms. Spinal congestion ; plethora spinalis. 

Definition. An abnormal fullness of the vessels of the meninges 
and cord : active when an arterial hypersemia ; passive when a venous 
hypersemia ; characterized by pain in the back, with more or less 
pronounced disorders of sensation and locomotion. 

Causes. Cold and exposure ; arrested menses ; arrest of a habitual 
hemorrhoidal discharge; malaria ; protracted erect posture ; injuries 
to the back ; certain spinal poisons, as strychnina, picrotoxinum, and 
alcoholic excesses. 

Pathological Anatomy. Active. The post-mortem appear- 

Iances are congestion of the meninges and cord, the same vessels 
supplying both, with numerous points of extravasation, due to the 
rupture of capillary vessels. The spinal fluid is increased in amount. 
Passive. A general bluish discoloration, owing to the abnormal 
fullness of the large anastomosing vessels ; the spinal fluid somewhat 
increased. 
Symptoms. Active. Dull pain in the dorsal or lumbar region, 
shooting into the hips and thighs, persistent and increased by pres- 
sure ; tenderness on motion ; tingling sensations in the limbs and feet, 
and sometimes in the hands and arms; a feeling of constriction 
about the abdomen is often present, with rigidity of the abdominal 



450 PRACTICE OF MEDICINE. 

muscles. Increased reflexes, with disorders of motility, and when the 
patient is in the recumbent position, jerking of the limbs. On attempt- 
ing to walk, it is accomplished with difficulty, from an incomplete loss 
of power. 

If the upper part of the cord be affected, dyspncea and palpitation 
occur. 

There often occur painful priapism and frequent nocturnal emis- 
sions. 

The above symptoms may be followed by a more or less pro- 
nounced temporary depression, the sensation diminished, and the 
lower limbs benumbed and heavy, the movements weak. 

The electro-contractility is preserved, and in many cases even in- 
creased or exaggerated. 

Duration, From a few hours to several days ; if longer, myelitis 
may result. 

Diagnosis. Anczmia causes more or less spinal irritability and 
tenderness ; but the history, pallor, and general weakness, unasso- 
ciated with defects of motility or sensibility, will prevent error. 

Spi7ial meningeal hemorrhage is more sudden in its onset, its vio- 
lence, and its range of symptoms. 

Myelitis a7id spinal meningitis have symptoms in common with 
spinal congestion, which will be pointed out when discussing those 
conditions. 

Prognosis. Favorable, recovery occurring in three or four days. 

If the symptoms show a tendency to linger, myelitis, more or less 
pronounced, will ensue. 

Treatment. Rest, but avoid lying on the back; cups or leeches 
along the spine, followed either by the iced or the hot douche, or hot 
sponges, with active purgation, to diminish the blood pressure. 

If the result of suddenly arrested perspiration, pilocarpus and a hot- 
air bath. If following suddenly arrested menses, aconitum. If 
associated with an active circulation, poiassiibromidum, or extractum 
gelsemii fluidum, X\y (0.3 Cc), every four hours, or extractum ergotce 
fluidum, f3ss-j (2-4 Cc), repeated p. r. n. ; and in all cases active 
purgation. 

For the passive form, treating the cause, ergota, digitalis, tonics, 
and purgatives. 



DISEASES OF THE SPINAL CORD. 451 



PACHYMENINGITIS SPINALIS. 

Synonyms. Pachymeningitis spinalis interna ; hypertrophic 
pachymeningitis ; pseudo-membranous pachymeningitis. 

Definition. An inflammation of the inner surface of the spinal 
dura mater ; characterized by violent pains in the head, neck, shoul- 
ders, and arms, followed by contractures and paralyses of the upper 
extremities. 

Causes. Exposure to cold and damp ; alcoholism ; syphilis ; gout ; 
injuries. 

Pathological Anatomy. Hypertrophic pachymeningitis is 
characterized by an exudation upon the inner surface of the dura 
mater, which gradually solidifies into a layer of compact connective 
tissue, this presses upon the* spinal cord and nerves, producing a 
myelitis and atrophic neuritis, resulting in muscular atrophy. 

The most frequent seat of this form of the affection is the cervical 
region, as first demonstrated by Charcot, whence the term cervical 
hypertrophic pachymeningitis. 

In the pseudo-membranous form a membranous exudation also 
occurs, in which large numbers of blood-vessels develop and rupture, 
the hemorrhagic extravasation forming a cyst — haematoma — which 
causes pressure on the cord and nerves. 

Symptoms. The onset is slow and gradual, with irregular chills 
and feveris hn ess, violent pains, and stiffness in the head, neck, shoul- 
ders, and arms, continuous, but subject to exacerbations, and associ- 
ated with a painful constriction of the upper thorax. Numbness and 
prickling occur in the arms, more marked in one than the other. 
Rarely nausea and vomiting occur. These symptoms may continue 
off and on for several months, the muscles of the painful parts 
atrophying, followed by spasmodic contraction, particularly of the 
hands and wrists, followed later by paralysis. 

The paralytic stage develops gradually, with weakness in the arms, 
associated with contractures and rigidity. The pain continues with 
anaesthesia, hyperesthesia, and trophic changes. Later, paraplegia 
with rigidity, exaggerated reflexes, and spinal epilepsy develop. 

The development of tuberculosis and nephritis during the progress 
of chronic cerebral and spinal diseases, which are the immediate 
cause of death, is a clinical observation. 



452 PRACTICE OF MEDICINE. 

The electro-contractility is lost. 

Prognosis. If early recognized and promptly treated, the hyper- 
trophic form may be improved. Generally, however, the prognosis 
is unfavorable. 

Treatment. Rest ; nutritious diet ; oleum morrhuce, and the 
hypophosphites ; large doses of potassii iodidum, and repeated but 
systematic counter-irritation. 

Symptomatic remedies for the pain and spasms are indicated. 



SPINAL MENINGITIS. 

Synonym. Leptomeningitis spinalis. 

Definition. Inflammation of the arachnoid and pia mater mem- 
branes of the spinal cord, either acute, subacute, or chronic ; charac- 
terized by pain in the back, rigidity of the muscles, disorders of motility 
and sensibility. It may be acute or chronic. 

Causes. The disease is rare and is always due to an infection 
from tubercle, syphilis, typhoid fever, or septicaemia, or the result of 
a traumatism. 

Pathological Anatomy. Acute. Hyperemia of the mem- 
branes, with swelling of the tissues, the result of serous infiltration, 
followed by purulent and fibrinous exudations. The roots of the 
spinal nerves are covered with exudation, and are swollen and soft. 
The cord proper is more or less congested and cedematous. 

Chronic. Adhesion of the membranes, with more or less accu- 
mulation of fluid, resulting in atrophic degeneration of the cord from 
pressure. 

If the disease is secondary to tubercle, these granulations are seen 
distributed over the pia, arachnoid, and inner surface of the dura. 

Symptoms. There are two stages : the first, the stage of irrita- 
tion; the second, the stage of paralysis of motion and sensation, with 
atrophy. Although an inflammatory affection, yet its onset is usually 
subacute, the febrile reaction being moderate, with intense boring 
pain in the back, aggravated by motion, rigidity of Ike spine, and a 
sense of constriciio?i around the body, — " the girdle." Spasmodic con- 
tractions of the muscles enervated by the nerves originating at the 
seat of the lesion, with inability to straighten the limbs. If the lower 
part of the spinal membranes is the seat, there occur retention of 



DISEASES OF THE SPINAL CORD. 453 

urine and constipation ; if upper part, dysphagia, dyspnoea, and feeble 
heart. The muscular contractions are excited or increased by motion, 
but uninfluenced by pressure. Reflex movements are not abolished. 
The rigidity and spasmodic contraction of the muscles are followed 
by paralysis, more or less complete, death following from paralysis of 
the muscles of respiration. 

If the inflammation extend to the medulla, the above symptoms are 
associated with disorders of speech, vomiting, and delirium. 

Electro-contractility lessened or absent, both as to motility and 
sensibility in the affected parts. 

Chronic form succeeds to the acute or originates spontaneously, 
and presents the same form and order of symptoms — excitation or 
irritation, and depression or paralysis. 

Diagnosis. The points of importance are : deep, boring pain in 
the back, aggravated by motion- but not by pressure, with spasmodic 
contraction of the muscles, followed by paralysis. 

Myelitis slight, or absence of pain, with earlier and more complete 
paralysis. 

Tetanus may be confounded with spinal meningitis. The points of 
distinction are : in the former occur early trismus with rhythmical 
spasms excited by irritation of the skin, whereas irritation of the skin 
does not in spinal meningitis produce muscular contractions, but 
movement of the limbs does do so ; progressively increasing, and not 
associated with fever ; usually a clear history of an injury. 

Prognosis. Generally unfavorable. Death is either sudden, from 
paralysis of respiration and of the heart, or gradually, the result of 
exhaustion. 

Critical discharges, such as profuse perspiration, urinary flow, or 
epistaxis occur, and are followed by rapid recovery. Cases recover- 
ing may have more or less pronounced partial or complete paralysis. 

Treatment. Rest in bed, upon the side or face. Cups or leeches 
along the spine, followed by ice, the hot douche, hot sponges, or 
mustard. Active purgation. 

If the result of syphilis, full doses of potassii iodidum, gr. x-xl 
(0.6-2.6 Gm.), combined with hydrargyri chloridum corrosivum, 
g r - !2Ws (0.0025-0.005 Gm.). 

For the paralytic stage, quinincE sulphas, gr. iij (0.2 Gm.), with 
extrachun belladonna alcoholic, gr. % (0.016 Gm.), three times a day, 
is sometimes useful. 



454 PRACTICE OF MEDICINE. 

For paralysis, the galvanic current to the spine and nerve trunks, 
and the faradic current to the affected muscles, with the deep injec- 
tion of strychnina and the use of massage. 



ACUTE MYELITIS. 

Synonyms. Acute or general diffuse myelitis ; transverse mye- 
litis ; softening of the cord. 

Definition. An inflammation affecting the substance of the 
spinal cord, which may be limited to the gray or white matter, and 
involve the whole or isolated portions of the cord. When the gray 
matter alone is inflamed, it is termed central myelitis ; when ,the 
white matter and the meninges, it is termed cortical myelitis ; it may 
be ascending, descending, or transverse in its extension. The dis- 
ease is characterized by more or less sudden and complete loss of 
motion and sensation. 

Causes. Following spinal meningitis ; exposure to cold and 
damp or wet weather ; injuries to the vertebrae ; prolonged func- 
tional activity of the cord; typhus fever; rheumatism; syphilis; 
puerperal fever, or, during the course of the exanthemata, arsenical, 
lead, or mercurial poisoning. 

Pathological Anatomy. Intense hyperemia of the substance 
of the cord, with extravasations, giving the tissues a reddish-brown 
or chocolate tint, and also serous transudations, resulting in soften- 
ing of the structure of the cord, the color changing to yellow and 
white, the nerve elements undergoing fatty degeneration, presenting 
the appearance and consistency of cream. The membranes also 
undergo more or less change. 

Symptoms. The severity of the symptoms depend upon the 
extent and location of the inflammation. 

The onset is usually sudden, with a chill, fever, 103 F. ( frequent 
Pulse, with alterations in sensibility and motility — to wit : pain in the 
back, aggravated by touch and by heat and cold, with sensations of 
formication (" pins and needles "), the limb feeling as if asleep, or 
else complete ancesthesia, associated with severe ?ieuralgic pains. 

The distinction between a?icesthesia, insensibility to touch, and 
analgesia, insensibility to pain, must be clearly determined. 

A sensation of constriction around the body and limbs, as if encircled 
by a tight cord, " the girdle pains," is a characteristic symptom, fol- 



DISEASES OF THE SPINAL CORD. 455 

lowed by rapidly developing paraplegia, complete in a few hours, 
with involuntary discharges. The reflex functions are usually abol- 
ished, as seen by attempting to cause movement of the limbs by tick- 
ling the feet or by striking the patella tendon ; rarely are they dimin- 
ished, very rarely exaggerated. The temperature of the affected 
limbs is lowered three or four degrees. 

Sloughs and bed-sores and muscular atrophy result if the anterior 
cornua — the trophic centres — are affected. 

The symptoms of loss of motion and sensibility, with rectal and 
vesical paralysis, are associated with more or less pronounced vomit- 
ing, hepatic disorders, irregularity of the heart, dyspnoea, dysphagia, 
apncea, and painful priapisms. The urine is markedly alkaline in 
reaction, finally developing cystitis. 

Among the late manifestations are shooting pains and spasmodic 
twitchings or contractions of one or all of the muscles of the paralyzed 
parts. 

The electro-contractility is abolished in the paralyzed parts. 

Diagnosis. Acute spinal meningitis is distinguished from acute 
myelitis by severe pains, increased by pressure, with muscular con- 
tractions increased by motion, followed by paralysis much less pro- 
found than the paraplegia of myelitis ; in spinal meningitis there exists 
cutaneous and muscular hyperesthesia, which are absent in myelitis. 

Congestion of the spinal cordis characterized by the mild character 
and short duration of all the symptoms. 

Hemorrhage in the spinal canal is abrupt with irritative symp- 
toms, slight paralysis, preserved reflexes, and electro-contractility. 

The principal diagnostic points of acute myelitis are the " girdle " 
around the limbs or body, rapid and complete paraplegia, loss of 
sensation, lowered temperature in the affected parts, early and per- 
sistent sloughing (bed-sores), and alkaline urine or cystitis. 

Hysterical paraplegia shows no trophic changes, no altered reflexes, 
slight atrophy, irregular anaesthesia, contractures with impaired sensa- 
tion of the contracted limb, and the presence of the stigmataof hysteria. 

LithcEmic parcesthesia, tingling and numbness of fingers and toes, 
might lead to error if the cerebral symptoms of lithaemia are overlooked. 

The diagnosis of the location of the lesion is made by a study of the 
height of the anaesthesia, the skin reflexes, and the distribution and 
extent of the paralysis, which are shown in the following table from 
Dana, based on that originally devised by Starr and modified by 
Mills and Dana. 



456 



PRACTICE OF MEDICINE. 



LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF 
THE SPINAL CORD. 



Segment. • 


Muscles. 


Reflex and Centres. 


Sensation. 


First cervi- 


Rectus laterales. 






cal. 


Rectus capitis. 
Anticus and posticus. 
Sterno hyoid. 
Stern o-thyroid. 






Second and 


Sterno-mastoid. 


Hypochondiium (?). 


Back of head to vertex 


third cervi- 


Trapezius. 


Sudden inspiration 


and neck. (Occipi- 


cal. 


Scaleni and neck. 


produced by sudden 


talis major, occipi- 




Omo hyoid. 


pressure beneath the 


talis minor, auricu- 




Diaphragm. 


lower border of ribs. 


laris magnus, super- 
ficialis colli, and su- 
praclavicular.) 


Fourth cer- 


Diaphragm. 


Pupillary (fourth cer- 


Neck. 


vical. 


Deltoid. 


vical to second dor- 


Shoulder, anterior sur- 




Biceps. 


sal). Dilatation of 


face. 




Coraco-brachialis. 


the pupil produced 


Outer arm. (Supracla- 




Supinator longus. 


by irritation of neck. 


vicular, circumflex, 




Rhomboid. 




external musculo-cu- 




Supra- and infra-spi- 




taneous, cutaneous.) 




natus. 






Fifth cervi- 


Deltoid. 


Scapular (fifth cervi- 


Back of shoulder and 


cal. 


Biceps. 


cal to first dorsal). 


arm. 




Coraco-brachialis. 


Irritation of skin 


Outer side of arm and 




Brachialis anticus. 


over the scapula 


forearm to the wrist. 




Supinator longus. 


produces contrac- 


(Supraclavicular, cir- 




Supinator brevis. 


tion of scapular 


cumflex, external cu- 




Deep muscles of shoul- 


muscles. 


taneous, internal cu- 




der-blade. 


Supinator lo ng u s . 


taneous, posterior 




Rhomboid. 


Tapping the tendon 


spinal branches.) 




Teres minor. 


of the supinator lon- 






Pectoralis (clavicular 


gus produces flexion 






part). 


of forearm. 






Serratus magnus. 






Sixth cervi- 


Deltoid. 


Triceps (fifth to sixth 


Outer side and front 


cal. 


Biceps. 


cervical). Tapping 


of forearm. 




Brachialis anticus. 


elbow tendon pro- 


Back of hand, radial 




Subscapular. 


duces extension of 


distribution. 




Pectoralis (clavicular 


forearm. 


(Chiefly external 




part). 


Posterior wrist (sixth 


cutaneous, internal 




Serratus magnus. 


to eighth cervical). 


cutaneous, radial.) 




Triceps. 


Tapping tendons 






Pronators. 


causes extension of 






Rhomboid. 


hand. 






Latissimus dorsi. 






Seventh cer- 


Triceps (long head). 


Anterior wrist (sev- 


Radial distribution in 


vical. 


Extensors of wrist 


enth to eighth cer- 


the hand. 




and fingers. 


vical). Tapping 


Median distribution in 




Pronators of wrist. 


anterior tendons 


the palm, thumb, in- 




Flexors of wrist. 


causes flexion of 


dex, and one-half 




Subscapular. 


wrist. 


middle finger. 




Pectoralis (costal part). 


Palmar (seventh cer- 


(External cutane- 




Serratus magnus. 


vical to first dorsal). 


ous, internal cuta- 




Latissimus dorsi. 


Stroking palm 


neous, radial, me- 




Teres major. 


causes closure of 


dian, posterior spinal 






fingers. 


branches.) 


Eighth cervi- 


Triceps (long head). 




Ulnar area of hand, 


cal. 


Flexors of wrist and 




back and palm, inner 




fingers. 




border of forearm. 




Intrinsic hand mus- 




(Internal cutaneous, 




cles. 




ulnar.) 



DISEASES OF THE SPINAL CORD. 



457 



LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF 
THE SPINAL CORD.— Continued. 



Segment. 


Muscles. 


Reflex and Centres. 


Sensation. 


First dorsal. 


Extensors of thumb. 




Chiefly inner side of 




Intrinsic hand mus- 




forearm and arm to 




cles. 




near the axilla. 




Thenar and hypothe- 




(Chiefly internal 




nar muscles. 




cutaneous and nerve 
of Wrisberg or lesser 
internal cutaneous.) 


Second dor- 






Inner side of arm near 


sal. 






and in axilla. (In- 
tercosto-humeral.) 


Second to 


Muscles of back and 


Epigastric (fourth to 


Skin of chest and ab- 


twelfth dor- 


abdomen. 


seventh dorsal). 


domen, in bands run- 


sal. 


Erectores spinae. 


Tickling mammary 


ning around and 






region causes re- 


downward, corre- 






traction of the epi- 


sponding to spinal 






gastrium. 


nerves. 






Abdominal (seventh to 


Upper gluteal region. 






eleventh dorsal). 


(Intercostals and 






Stroking side of abdo- 


dorsal posterior 






men causes retrac- 


nerves.) 






tion of belly. 








Vasomotor centres. 








Second dorsal to 








second lumbar. 




First lumbar. 


None. 


Cremasteric (first to 


Skin over groin and 






third lumbar). 


front of scrotum. 






Stroking inner thigh 


(Ilio-hy pogastric, 






causes retraction of 


ilio-inguinal.) 






scrotum. 




Second lum- 


Vastus interims. 


Patellar. Striking 


Outer side and upper 


bar. 




patellar tendon 


front of thigh. Lum- 








bar region. (Genito- 






leg. 


crural , external cuta- 
neous.) 


Third lum- 


Sartorius ; adductors 




Front and outer side 


bar. 


of thigh. 




of thigh. Inner side 




Flexors of thigh. 




of leg and foot. 


Fourth lum- 


Extensors of knee. 


Gluteal (fourth to fifth 


Inner side of thigh, leg, 


bar. 


Abductors of thigh. 


lumbar). Stroking 


and foot. (Internal 






buttock causes dimp- 


cutaneous, long sa- 






ling in fold of buttock. 


phenous, obturator.) 


Fifth lumbar. 


Outward rotators. 


Achilles tendon. Over- 


Back of thigh and 




Flexors of knee. 


extension causes 


outer side of leg and 




Flexors of ankle. 


rapid flexion of 


ankle; sole; dorsum 




Peronei. 


ankle, called ankle 


of foot. (External 




Extensors of toes. 


clonus. 


popliteal, external 
saphenous, musculo- 
cutaneous, plantar.) 


First and 


Calf muscles. 


Plantar (fifth lumbar 


Back of buttock and 


second sa- 


Glutei. 


to second sacral). 


thigh ; side of leg and 


cral. 


Peronei. 


Tickling sole of foot 


ankle ; sole ; dorsum 




Extensors of ankle. 


causes flexion oftoes 


of foot. 




Small muscles of foot. 


and retraction of leg. 




Third, fourth, 


Perineal. 


Genital centre. 


Circumanal region, 


and fifth sa- 


Muscles of bladder, 


Vesical centre. 


anus, rectum, penis, 


cral. 


rectum, and exter- 


Anal centre. 


urethra, vagina, 




nal genitals. 




perineum. 

(Small sciatic, 
pudic, inferior hem- 
orrhoidal, inferior 


39 






pudendal.) 



458 PRACTICE OF MEDICINE. 

Prognosis. Depends upon the location of the lesion and com- 
pleteness of the symptoms. 

If the paralysis is of the ascending variety, death occurs within a 
few days, from paralysis of the muscles of respiration. 

If the trophic centres are affected, there occur bed-sores, intense 
pyelo nephritis and cystitis and changes in the joints; death from 
exhaustion in several weeks. 

Central myelitis, or inflammation of the gray matter, is rapid in its 
progress, death occurring in a week or two. 

The morbid process may be arrested and the general health 
restored, but some spinal symptoms will persist. 

Treatment. Absolute rest is essential to even secure a palliation 
of the symptoms. 

Locally, considerable relief follows the use of hot-water bags or 
sponges dipped in hot water and applied along the spine every few 
hours. 

The remedies most strongly recommended are : digitalis, strychnine? 
sulphas, ergota, belladonna, bromides, cimicifuga, and quinince 
sulphas ■, although I have never observed a cure with any plan of med- 
ication after the disease was fairly established. Cases due to syphilis 
are benefited by large doses of potassii iodidum. Gray reports having 
administered 700 grains daily before improvement began. 



INFANTILE SPINAL PARALYSIS. 

Synonyms. Myelitis of the anterior horns ; poliomyelitis ante- 
rior acuta ; essential paralysis of children ; atrophic paralysis of chil- 
dren. 

Definition. A rapidly developed inflammation of the anterior 
horns of the gray matter of the cord, occurring suddenly in children, 
at times in adults, — acute spinal paralysis of adults, — characterized 
by mild fever, muscular tremors and twitchings, and paralysis of 
groups of muscles, followed by more or less atrophy. 

Causes. Essentially a disease of early life — the second month to 
the third or fourth year. The fact of its having occurred in adults 
must be borne in mind. Cold and damp; dentition (?) ; injuries to 
the spine ; developed during convalescence from the acute exanthe- 
mata. 



DISEASES OF THE SPINAL CORD. 459 

Pathological Anatomy. The early changes are: Medullary 
hypersemia, vascular exudation and inflammatory softening, although 
the naked eye may not recognize any changes. Microscopical exam- 
ination reveals inflammatory softening of the anterior horns of the 
gray matter. Among other constant lesions are atrophic degenera- 
tion of the multipolar ganglion cells and of the anterior nerve roots. 

The changes noted as occurring in the cord are usually limited to 
the dorso-lumbar and cervical enlargements. 

As a direct result of the changes in the trophic centres and the nerve 
degeneration of the muscular fibres supplied, there ensue changes in 
the bones and joints, leading to great deformities. 

Symptoms. The onset of the affection varies ; it may be acute, 
subacute, or chronic ; it is usually sudden, with an attack of mild 
fever of a remittent type, of a few days' duration, on recovery from 
which it is noticed that the child is paralyzed. Rarely, the paralysis 
may be preceded by convulsions. 

The paralysis may affect both arms and both legs, the legs alone, 
or only one of the four extremities ; it may, but very rarely, be a 
hemiplegia. As a rule, however, the leg suffers more frequently than 
the arm : in paralysis of the leg the muscles below the knee suffer 
more severely than those above. The bladder and rectum are not 
affected, or if so, only temporarily, nor can anaesthesia or numbness 
be detected. The temperature of the paralyzed limb is low and the 
appearance cyanosed. After a few days there is a slight improve- 
ment in the paralyzed parts, although the muscles show a rapid 
wasting, which is progressive until all muscular tissue is gone. 

The reflex movements are impaired or abolished. 

The electro-contractility by the faradic current is abolished in the 
paralyzed parts. 

With the galvanic or constant current the " reactions of degenera- 
tion " are developed. To fully understand the meaning of this term 
a knowledge of the normal electrical reactions is necessary. 

The normal formula for the production of muscular contraction in 
the physiological state are as follows, the strength of the current being 
barely capable of causing fair contractions : 

First. The most effective contractions are produced by the cathode 
{negative) pole on closing the circuit (C. C). 

Second. The second most effective are produced by the anode {pos- 
itive) pole on closing the circuit (A. C). 



460 PRACTICE OF MEDICINE. 

Third. The next most effective is by the anode pole on opening the 
circuit (A.O.). 

Fourth. Cathode pole contractions on opening circuit are rarely 
seen in the physiological state (C. O.). 

The " reactions of degeneration " are shown by any reversal of the 
regular formulae — to wit : if the anodal closure (A. C.) shows stronger 
contractions than c athodal closure (C. C.) ; still greater degeneration is 
shown if anodal opening '(A. O.) contractions are stronger than either of 
the above ; andjnost complete degeneration is shown by the complete 
reversal of the normal formulae as shown by distinct cathodal opening 
(C. O.) contractions. 

Sequelae. Amongst the deformities resulting from the paralysis 
are the different forms of talipes. 

Talipes equinus, the result of paralysis of the antero-external mus- 
cular group of the leg. 

Equino-varus, the result of paralysis of the antero-external mus- 
cular group of the leg, together with the adductors of the foot. 

Talipes calcaneus, the result of paralysis of the muscles of the calf 
of the leg. 

Talipes cavus, — "pes cavus," — characterized by the hollowing of 
the sole of the foot, with prominence of the instep, the result of 
paralysis of the calf muscles with contraction of the long flexor of 
the toe or the long peroneus — the foot flexors. 

Diagnosis. The recognition of acute poliomyelitis is not always 
possible at the onset or during its early days, as localized paralyses 
are difficult of detection in children, but immobility of one leg or arm 
in children with febrile symptoms or following convulsions is always 
an indication of poliomyelitis. After the initial stage has passed, the 
presence of paralysis, wasting, presence of R. D. (reactions of degen- 
eration), loss of reflexes, and the absence of anaesthesia, render the 
diagnosis very easy. 

Hemiplegia from acute cerebral affections in children can be dis- 
tinguished from infantile paralysis by the" disorders of intelligence 
and the special senses, and the perseverance of the normal electro- 
contractility. 

Paralysis of myelitis occurs in older persons, and is associated with 
disturbances of the genito-urinary organs and bed-sores. 

Pseudo-muscular hypertrophy, with paralysis, begins gradually, 
becoming progressively worse with increase in the size of the limbs. 



DISEASES OF THE SPINAL CORD. 461 

Prognosis. More or less paralysis, with muscular wasting, always 
results, although there is no doubt that the extent can be greatly 
lessened by early recognition and treatment. 

Treatment. The diagnosis during the initial fever is impossible, 
so that its treatment is symptomatic. On the appearance of the 
paralysis, complete rest, hot spinal douche, mild galvanism, and 
internally, quinina, belladonna, ergota, and potassii iodidum. 

With the improvement that follows the above measure, use inter- 
nally tinctura nucis vomica, tt\j — i i j (0.06-0.2 Gm.), three times daily, 
or hypodermic injections of strychnince sulphas, gr. yg-xijo (o-°°4- 
0.00065 Gm.), according to age, twice a week, and faradism to the 
paralyzed muscles. 



CHRONIC PROGRESSIVE BULBAR PARALYSIS. 

Synonyms. Glosso-labio-laryngeal paralysis ; bulbar paralysis. 

Definition. A chronic degenerative affection of certain nuclei 
of the medulla oblongata ; characterized by a slowly progressive 
bilateral paralysis of the tongue, lips, palate, pharynx, and larynx, 
with atrophy of the tongue and lips. 

Causes. Obscure. Rare before the fortieth year. Among many 
others may be named cold, rheumatism, gout, syphilis, and injuries 
about the neck. 

Pathological Anatomy. " Degenerative atrophy of the gray 
nuclei in the floor of the fourth ventricle ; with atrophy and gray dis- 
coloration of the nerve roots from the medulla, especially of the facial 
and hypoglossal nerves." "Atrophy and disappearance of the motor 
ganglion cells are always to be noted. It may be the sole lesion." 

" The nerves going to the muscles exhibit sclerosis of the neuri- 
lemma, and the degenerative atrophy is found in the nerve roots 
coming from the bulb." 

Symptoms. The disease begins insidiously. There is first 
noticed some difficulty in articulation, from want of precision in 
movements of the tongue, particularly in the use of the lingual con- 
sonants, /, n, r, and /, which increases until that organ is completely 
paralyzed. The paralysis gradually invades the soft palate and pharyn- 
geal muscles, causing difficulty in deglutition, of the orbicularis oris 
preventing closure of the lips, of the laryngeal muscles, interfering 



462 PRACTICE OF MEDICINE. 

with articulaiion. With the increasing loss of power in the tongue 
and lips is also a gradual atrophy of these muscles ; the atrophy- 
usually antedates the paralysis. When the disease is fully devel- 
oped, the condition of the patient is most pitiable, indeed ; articulation 
is impaired or impossible, deglutition interfered with, the lips remain- 
ing apart allowing the saliva to dribble from the mouth and liquids 
to return through the nose with attempts at swallowing. As the 
malady progresses, the pneumogastric nucleus becomes involved, 
resulting in loss of voice, difficulty of respiration, and cardiac irregu- 
larity. The general health gradually suffers from insufficient nutri- 
tion and imperfect respiration, although the mind is clear until the 
end. The "reactions of degeneration " are present. ' 

Besides the chronic bulbar paralysis, there are two acute forms 
with the same symptoms as the chronic cases, only they develop 
suddenly, one, the result of hemorrhage into the medulla, which at the 
onset has vertigo, vomiting, loss of power in the limbs, and slight 
sensory disturbances, all of which disappear, leaving the glosso- 
labio-laryngeal paralysis ; the second form comes suddenly, with 
fever, vomiting, and loss of power in the limbs, soon disappearing, 
leaving the characteristic bulbar symptoms ; this variety is inflam- 
matory and closely allied to acute poliomyelitis. 

Diagnosis. It can hardly be confounded with any other malady. 

Prognosis. Unfavorable. The duration is from one to five 
years. 

Treatment. Entirely symptomatic. " Galvanism is the most 
promising remedy. Stabile applications, the electrodes on the mas- 
toid processes and in the opposite direction, galvanization of the 
sympathetic, and applications to the lips, tongue, and fauces, should 
be persistently used" (Bartholow). 



PROGRESSIVE MUSCULAR ATROPHY. 

Synonyms. Wasting palsy ; chronic spinal muscular atrophy; 
chronic poliomyelitis; amyotrophic lateral sclerosis. 

Definition. A chronic progressive motor paralysis and atrophy 
of certain groups of muscles. The paralysis proportionate to the 
wasting or fibrillary atrophy. 

Causes. Most frequent in males between twenty-five and fifty 



DISEASES OF THE SPINAL CORD. 463 

years of age, and in many instances is hereditary. A predis- 
position seems to exist in those who habitually use one set of 
muscles (muscular strain). Exposure to cold and damp; lead; 
syphilis ; injuries to the spinal column. Following such acute 
diseases as diphtheria, measles, acute rheumatism, typhoid and 
typhus fevers. 

Pathological Anatomy. Two theories as to the origin of the 
pathological changes are held : one that the initial lesion is in the 
cord (Charcot), the other in the muscular interstitial connective tissue 
(Friedreich). 

The morbid alterations are of two groups — spinal and muscular. 

The spinal changes consist in the atrophy and degeneration of the 
anterior columns, wasting and disappearance of the multipolar gan- 
glion cells of the anterior horns, with hyperplasia of the neuroglia; 
rarely, the hyperplasia extends to the lateral columns (amyotrophic 
lateral sclerosis) ; also wasting, atrophy, and degeneration of the 
anterior nerve roots. 

The muscular changes consist of a progressive wasting of the mus- 
cular tissue, with increase of the interstitial connective tissue. " The 
final result is that the muscle is converted into a mere fibrous band 
with numerous fat-cells, the development of this latter material taking 
place outside of the muscular elements and in the newly-formed 
connective tissue " (Bartholow). 

Symptoms. The invasion is gradual, the disease having been 
in progress some weeks or months before the patient is aware of its 
existence. 

In the immense majority of cases the disease is permanently lim- 
ited to one or a few groups of muscles in the upper, or more rarely in 
the lower, extremities. The only muscles not yet known to be at- 
tacked are those of mastication and those that move the eyeball 
(Roberts). 

Fibrillary contraction is an early symptom, continuing more or 
less marked so long as any muscular fibres remain. It consists of 
wave-like movements of the muscles, excited automatically, by 
draughts of air or percussion. Coincident with the wasting is loss oj 
power, disorders of sensation, coolness and pallor of the surface. 

The natural roundness and contour of the body and limbs are 
changed, the bones standing out in unaccustomed distinctness, giving 
the individual the appearance of a skeleton clothed in skin. 



464 PRACTICE OF MEDICINE. 

Four types of the disease are recognized : i, the hand-type ; 2, the 
juvenile type ; 3, the infantile facial type ; 4, the peroneal type. 

The hand-type : wasting begins in the hand, and particularly in 
the short muscles of the thumb and the ball of the little finger — the 
thenar and hypothenar eminences. The complete atrophy of the 
thumb muscles produces such a change in the shape of the hand as 
to give it the name of the ape-hand. Soon, and may be at the same 
time, wasting of the dorsal interosseous is observed, with consequent 
loss of power in these muscles, producing the deformity known as 
claw-hand. Soon the deltoid and other arm muscles are involved in 
the wasting and contraction. 

The juvenile type (Erb) : a rare form, affecting the muscles of the 
shoulder and upper arm, and less commonly the muscles of the lower 
extremities. This form follows after a time in the hand-type, but Erb 
described cases occurring primarily in these parts. Rarely, wasting 
in the suprascapular muscles, with fibrillary contractions, is seen 
alone. 

The infantile facial type : involves the muscles of expression, 
changing entirely the appearance of the individual and giving the 
eyeballs a prominence from atrophy of the surrounding muscles, not 
unlike exophthalmos. After a time, the muscles of the shoulder and 
arm are involved, except the supraspinalis, infraspinalis, and the 
flexors of the hand and fingers. 

The peroneal type : wasting first appears in the muscles of the legs, 
extending to the feet, producing single or double club-foot. After a 
time, the muscles of the hands and arms are involved, with the conse- 
quent deformities. Vasomotor changes are observed in this type. 

Rarely, all the types are more or less blended in the same indi- 
vidual. Usually, the electro-contractility is preserved so long as 
muscular fibres remain. 

Diagnosis. When wasting palsy is fully developed, its diagnosis 
is a simple matter. In its early stages a doubt may exist, but atten- 
tion to the history, symptoms, and progress will determine the ques- 
tion. 

Syringomyelia often begins with muscular atrophy as a marked 
symptom, and may be confounded with wasting palsy, the chief points 
of distinction between which are : the loss of power of perceiving heat, 
or, often, to distinguish between heat and cold, and the appearance 
of trophic changes, such as a dusky or purplish hue of the hands, 



DISEASES OF THE SPINAL CORD. 465 

with a uniform thickness resembling myxcedema, the development of 
blebs and ulcers, and changes in the nails. Arthropathies are some- 
times met with. 

Prognosis. Very unfavorable, although the danger to life is often 
very remote. The disease may be arrested and remain stationary for 
years. 

Treatment. Internal medication seems to have no effect on the 
malady, although if mineral poisoning be suspected, ftotassii iodidum 
should be employed, and if syphilis be suspected, a course of potassii 
iodidum and hydrargyrum should be administered. . Arsenicum, 
strychnines sulphas, and oleum morrhuce, with a generous diet, are 
amongst the remedies indicated. 

If the disease is the result of overworking any set of muscles, these 
must be allowed a rest. 

" The most effective remedy in wasting palsy is, undoubtedly, gal- 
vanism. Numerous observations attest its value when applied locally 
to the affected muscles " (Roberts). 

I have seen improvement from the faradic current to the affected 
muscles, the strength being simply sufficient to produce contractions. 

Massage is a valuable adjuvant to the electrical treatment, as are 
hot sponging and rubbing along the spine. 

Prof. Bartholow " has apparently effected great improvement in a 
case, confined as yet to the left upper extremity, by the injection 
of glycerin solution into the wasting muscles." 



SPINAL SCLEROSIS. 

Synonym. Duchenne's disease. 

Definition. A myelitis; an increase in the connective tissue of 
the spinal cord, with atrophy of the nerve structure proper. 

Varieties. I. Lateral sclerosis. II. Posterior sclerosis, or loco- 
motor ataxia. III. Ataxic paraplegia. IV. Cerebro spinal sclerosis. 

Causes. Generally a hereditary neuropathic diathesis ; syphilis; 
alcoholism ; mineral poisons ; shock or injuries to the cord ; exposure 
to cold and wet; mostly occurring between the ages of thirty-five and 
fifty-five ; males more liable than females. It is said that railroad 
enginemen and firemen, as well as conductors and other trainmen, 
suffer from this and other spinal diseases by reason of the continual 
40 



466 PRACTICE OF MEDICINE. 

concussion of railway travel. The freedom from the disease in the 
negro has been noted by Mitchell. 

Pathological Anatomy. The changes in the cord are gradual 
in their development and follow a longitudinal instead of a transverse 
direction. 

The form, consistency, and color of the cord are altered, it being 
atrophied, indurated, and of a grayish color. 

The changes are hyperplasia of the connective tissue, with granular 
degeneration, atrophy, and disappearance of the proper nerve ele- 
ments. The nerve roots undergo the same fibroid change. The 
joints undergo remarkable atrophic degeneration — the arthropathies 
or Charcot joints, consisting of an osseous hyperplasia, the joint 
enlarging: to an enormous extent. 



PRIMARY LATERAL SCLEROSIS. 

Synonyms. Antero-lateral sclerosis; spasmodic tabes dorsalis 
(Charcot) ; spastic spinal paralysis (Erb). 

Definition. A degeneration of the lateral columns of the cord; 
characterized by paraplegia, contractures of the muscles, with exag- 
gerated reflexes. 

Pathogeny. The exact morbid condition is still a subject of dis- 
cussion. The site of the lesion is the lateral white columns, in some 
cases extending to the anterior horn, and involving the whole length 
of the cord. The changes consist in an interstitial hyperplasia of the 
connective tissue, and an atrophy of the nerve elements. 

Symptoms. The onset of the disease is very gradual, with in- 
creasing feeling of heaviness and weakness in the limbs, progressing 
to a complete paraplegia. There are also jerking and twitching with 
cramps and stiffness of the muscles of the paretic limbs. The spasms 
of the legs gradually increase in extent as the power lessens, until at 
last the legs, whenever extended, pass into a condition of strong 
extensor spasm, rigidly fixing them to the pelvis, so that the patient 
lies rigid ; if one leg is lifted from the couch by the observer, the other 
leg is moved also. The spasm may be such that the knee cannot be 
passively flexed by any force that can be applied to it until the spasm 
has lessened. When flexed, the limb is comparatively supple; 
but if it is then extended, the spasm instantly returns, making the 



DISEASES OF THE SPINAL CORD. 467 

limb rigid, and often completing the extension, just as the blade of a 
knife opens out under the influence of its spring, "clasp-knife 
rigidity." Occasionally, there occur brief flexor spasms, drawing the 
legs up. 

Seguin called attention to "a desire to micturate that is far less 
controllable than it should be in a healthy person." 

The knee-jerk is greatly exaggerated, and there can also be devel- 
oped rectus-clonus and ankle-clonus. 

The spastic gait is characteristic, termed by Hammond " the wad- 
dle " ; the legs drag behind and are moved forward as a rigid whole, 
the toes catching against the ground, the patient showing a tendency 
to fall forward. 

Sensation is unaffected. As the morbid process extends upward, 
the superior extremities suffer in the same manner as those of the 
lower. 

Electro-contractility early impaired and gradually declining until 
abolished. 

Diagnosis. The gradual development of weakness in the legs, 
excess of myotatic irritability, and spasms with developing spastic gait 
render the diagnosis clear. If the symptoms develop suddenly or 
acutely, the morbid condition is not of the degenerative variety. 

Prognosis. Complete recovery rare.. If the condition is early 
recognized, its progress may be held in check for a long time. 

Treatment. Rest of the first importance. Every means to pro- 
mote the general health. If the result of lues or mineral poisons, 
increasing doses of potassii iodiduni, or aurii et sodii chloridum. 
Argenti nitras, or oxidum, often retards the hyperplasia of connective 
tissue. Benefit may sometimes follow the use of a weak galvanic 
current, but as a rule electricity is disappointing in central diseases. 



LOCOMOTOR ATAXIA. 

Synonyms. Posterior spinal sclerosis ; tabes dorsalis. 

Definition. A chronic degeneration of the posterior columns of 
the spinal cord and the posterior nerve roots, characterized by loss 
of co-ordination, neuralgic pains in the limbs, loss of sensation and 
reflexes, and visceral and trophic changes. 

Pathogeny. " A general disease of the nervous system, affecting 



468 PRACTICE OF MEDICINE. 

both central and peripheral portions, though mainly limited to sensory 
or afferent structures" (Peterson). "A progressive destructive pro- 
cess which has a selective influence on certain tracts in the posterior 
columns with their roots and ganglia and to a less extent on the 
peripheral nerves, particularly the optic. The nerve fibres of the cord 
are first involved. Their destruction is not a simple wasting, but is 
accompanied with evidence of irritation, such as swelling of axis- 
cylinders and, secondarily, proliferation of connective tissue and 
slight congestion " (Dana). 

Symptoms. Locomotor ataxia may be divided into three periods : 
i , disturbances of sensation ; 2, loss of co-ordinating power ; 3, paralysis. 

The onset of the disease is gradual, by sharp, darting, electric-like 
pains in the lower limbs, with disorders of the gastro-intestinal and 
genito-urinary tracts. Associated with the pains is a loss of sensation 
in the feet, the patient being unable to distinguish between hard and 
soft substances in walking, and, if the upper portion of the spinal 
cord be affected, is unable to co-ordinate the muscles of the fingers 
sufficiently to button his clothing. A sensation of formication over 
the surface, especially over the lower limbs, and about the waist, the 
knee, and the ankle, is present ; there is nearly always a feeling of 
constriction about the trunk — the girdle. 

Loss of co-ordination, or ataxia, the subject being unable to walk 
upon a straight line with his eyes closed, and with difficulty if his 
eyes are opened. Inability to preserve the erect position with the 
feet close together, the body swaying widely and the patient falling 
on standing with closed eyes, — Romberg's symptom, and as the 
malady progresses he throws his feet and legs in the most grotesque 
manner when walking. Although the patient is unable to co-ordinate 
the muscles, their power is not lost, for, on being supported, he can 
kick or strike with his usual force. 

The sight is early impaired, due to atrophy of the optic nerve, caus- 
ing either double vision or inability to distinguish between different 
colors. Very early there is loss of pupil reflex to light, the reaction to 
accommodation being present — Argyll- Robertson symptom. As the 
disease progresses, sensation becomes more and more blunted and 
p lin is slowly recognized, frequently several minutes elapsing before 
the pricking of a pin is appreciated. A characteristic sign of the 
disease is the abolitio7i of the patellar-tendon reflex — Westphal's 
symptom — as well as other reflexes in the lower limbs. Loss of the 






DISEASES OF THE SPINAL CORD. 469 

sensation of temperature also occurs. The electro-contractility is 
decreased in the affected limb. General emaciation is marked. 

Vasomotor and trophic symptoms, more or less pronounced, occur 
in all cases. " Perforating ulcers" of the feet, loss of hair in spots, 
changes in the nails, and local sweatings are the more common. 
Muscular atrophy, either localized or general, is not infrequent. 

Frankel, under the term " hypotonia," describes a condition found 
in tabetic persons in which the patient, lying on a flat surface, can com- 
pletely straighten his legs when at right angles to the body, which can- 
not be done by a normal man, whose knees will be bent when legs 
are at right angles with body. 

Either early or late in the disease occur disturbances in micturition 
and loss of sexual power and often desire. There also occur, in a 
fair number of cases, painless swelling and disintegration of various 
joints, particularly the knee and elbow — the tabetic arthropathies, or 
Charcot joints. 

At any period of the disease peculiar crises or neuralgic attacks 
occur ; if griping pains in stomach with vomiting, gastric crises ; if 
renal pain" or colic with disturbed urinary flow, nephralgic crises ; if 
pain in bladder, vesical crises ; if pain in rectum with haemorrhoids, 
rectal crises; if severe paroxysm of coughing, bronchial crises; if 
constriction of the throat with dyspnoea, laryngeal crises ; if cardiac 
pain and tachycardia, cardiac crises. 

Paralysis finally ends the suffering of the patient. There is gener- 
ally an entire absence of cerebral phenomena, although rarely delu- 
sions or dementia develop toward the end of the malady. 

Diagnosis. There are three pathognomonic symptoms of loco- 
motor ataxia, the presence of which makes the diagnosis positive ; they 
are Westphal's symptom — absence of patellar reflex ; Romberg's 
symptom — swaying of body and inability to maintain erect position 
with closed eyes ; the Argyll-Robertson symptom — loss of pupil reflex 
to light, but reaction to accommodation retained ; Frankel's symptom 
— hypotonia. 

Chro?iic myelitis is characterized by paralysis, and the course of 
the affections are otherwise so different that an error should not occur. 

Disease of the cerebellum presents symptoms of disordered co-ordi- 
nation, but they are the result of vertigo, and associated with headache, 
nausea, and vomiting, with absent neuralgic pains and eye symptoms. 

Paraplegia is a true paralysis, while locomotor ataxia is not. Neu- 
ralgic pain is not a symptom of paraplegia. 



470 PRACTICE OF MEDICINE. 

Multiple neuritis shows loss of power with pain, but does not present 
the three pathognomonic symptoms mentioned above. 

Prognosis. Unfavorable. Rarely the progress has been retarded 
for a long time. There are some claims of recoveries of locomotor 
ataxia in the early stage, but that a cure of a genuine case, extending 
to the second stage, is ever effected seems very questionable. 

Treatment. In the management of locomotor ataxia, rest, as 
nearly absolute as possible, is of the first importance. It will be all 
the more effective if it be in bed for a period of several months. 

Following the suggestion of Erb, use may be made of cold along 
the spi?ie, in the shape of cold sponging, cold spinal pack, or short 
applications of the cold douche to the spine. The galvanic continuous 
current along the spinal column is warmly advocated, with faradism 
to the wasting muscles. 

Potassii iodidum, or hydrargyri chloridum corrosivum, in full doses, 
or aurii et sodii ckloridu7n, gr. 2V (°-°°3 Gm.), three times a day, often 
remarkably retard the progress of the affection. The best results are 
obtained, however, fiom argenti nitras, gr. ]i-Yz (0016-0.03 Gm.), 
or oxidum, gr. y z (0.03 Gm.), three times a day, withholding it at 
intervals of a few weeks to prevent discoloration of the skin (argyria). 

Temporary success at least seems to have followed, in some cases 
of locomotor ataxia in the second stage, from the ''suspension treat- 
ment" recommended by Charcot. The treatment consists in the 
suspension of the patient during a period varying from one to four 
minutes, by means of the Sayre apparatus for applying the plaster 
jacket in spinal deformities. 

The severe and sharp pains require treatment, at first giving prefer- 
ence to any of the substitutes of opium, but finally opium itself will 
have to be resorted to. The actual cautery applied to the back once 
a month is said to relieve the pains. 

The diet should be of a nutritious, easily-assimilated character. 
Nutrition can also be promoted by the use of oleum niorrhuce, and 
syrupus calcii lacto-phosphatis, or the hypophosphites and strychnina. 



ATAXIC PARAPLEGIA. 

Synonyms. Combined lateral and posterior sclerosis ; antero- 
lateral sclerosis. 

Definition. A chronic degeneration of the lateral pyramidal 



DISEASES OF THE SPINAL CORD. 471 

tracts and of the posterior columns of the spinal cord ; characterized 
by gradually developing paraplegia, with ataxia and spasms of the 
limbs. 

Causes. The causes are not so well determined as in other vari- 
eties of spinal sclerosis. 

Pathogeny. A sclerosis of the lateral and posterior columns of 
the spinal cord. It is to be noted that the posterior columns show 
the morbid changes higher up than in locomotor ataxia, — the dorsal 
rather than the lumbar regions, — and that the root-zone of the postero- 
external column is much less involved. Nor do the lateral tracts 
show the same degree of involvement as in spastic paraplegia. 

Symptoms. The onset is slow and gradual, with toss of power 
in the lower extremities. The muscles involved are particularly the 
flexors of the thigh and knee. One leg may be weaker than the other. 
There is also ataxia, the patient being unsteady when standing with 
feet together (tabetic swaying), and he tends to fall if the eyes are at 
the same time closed. Spasms of the lower extremity gradually de- 
velop and finally become as marked as in spastic paraplegia. The 
knee jerk reflex is increased, quick and extensive, and rectus- and 
ankle-clonus can be developed. The sexual power is early lost. In- 
continence of urine is frequent. Sensation is unimpaired and neu- 
ralgic pains are absent, as are eye symptoms. 

Diagnosis. The conditions ataxic paraplegia is most liable to 
be mistaken for are locomotor ataxia and spastic paraplegia. The 
presence of knee-jerk and loss of power in lower extremities are of 
value in discriminating from locomotor ataxia. Spastic paraplegia 
is not associated with ataxia — indeed, ataxic paraplegia is spastic 
paraplegia///^ inco-ordination. 

Prognosis. Unfavorable. The condition is progressive. 

Treatment. The same plan of treatment may be tried as recom- 
mended for lateral or posterior sclerosis. 



CEREBROSPINAL SCLEROSIS. 

Synonyms. Multiple sclerosis of the brain and cord ; cerebral 
sclerosis; spinal sclerosis ; disseminated sclerosis (Charcot). 

Definition. A degenerative disease of the brain and spinal cord ; 
characterized by pains in the back, disorders of sensation, loss of 



472 PRACTICE OF MEDICINE. 

co-ordination, tremor on motion, scanning speech, and some mental 
impairment. 

Pathogeny. The disease consists in the development of patches 
of grayish, translucent, tough nodules, varying in size from a minute 
microscopical object up to the size of a walnut, varying in number 
and widely distributed in the white matter of the hemispheres, ven- 
tricles, optic thalamus, corpus striatum, peduncles, pons, and cere- 
bellum, while in the cord they are found in both the white and gray 
matter and in the columns. The deposits are also found in the nerve 
roots and nerve trunks. The nodules are composed of the neuroglia, 
much altered, and a newly-formed connective tissue. The result of 
the growth of the nodules is pressure upon the nerve structure, ending 
in its degeneration. 

Symptoms. -Charcot divided disseminated sclerosis into three 
varieties, depending upon the site of the marked changes, as the 
brain, the cord, or a combination of the two. The latter variety is 
the more common. 

Rarely, the malady is ushered in with apoplectiform symptoms, but 
generally the onset is insidious, with pains more or less severe in the 
limbs and back, which are attributed by the patient to rheumatism. 
Also a feeling of formication, itching, and burning in the limbs. Loss 
of co-ordination of the hands in writing, or the feet in walking, or a 
jerky co-ordination, followed after a time by paresis, more or less 
general, with contracture of the muscles. Voluntary movements of 
the paretic limbs develop a tremor — the shaking tremor — which sub- 
sides when the limbs are at rest — intention tremor, with shaking of 
head. An early and frequent condition is nystagmics. The loss of 
co-ordination, with tremor and with contractures of the muscles 
of the legs, has given rise to the "waddle," or "hop" gait when 
walking. There are also present headache, vertigo, mental impair- 
ment, with an unnatural contentment of the feelings and with the 
surroundings. A scanning or slurring speech ; disorders of vision, 
from optic-nerve atrophy, and hearing ; sexual disturbances, vesical 
disorders, gastric and other crises, and often the development of 
bed-sores. • 

Knee-jerk and wrist-jerk are exaggerated, and ankle-clonus is 
present. 

The disease is progressive, the symptoms developing as the various 
nerve tracts are invaded. 






DISEASES OF THE SPINAL CORD. 473 

Persons with multiple sclerosis are very liable to develop pulmonary 
consumption or chronic nephritis. 

Duration. Ranges from a year to twenty years, an average 
being five or ten years. 

Diagnosis. Keeping in mind the following general symptoms 
an error can be avoided : pains in limbs and back, loss of co-ordina- 
tion in the feet and hands, muscular weakness with contractures, 
intentional tremor, nystagmus, scanning speech, disordered vision, 
increased tendon reflexes, and vertigo. 

Paralysis agitans may be mistaken for disseminated sclerosis. 
The chief points in the diagnosis are the presence in paralysis 
agitans of the fine tremor continually without shaking of the head, 
with a peculiar flexion and rigidity of the hand, while in cerebro- 
spinal sclerosis the tremor is produced only on movement of the 
muscle, and is associated with shaking of the head. Paralysis 
agitans, a disease of middle life, sclerosis under forty years. Changes 
in the voice, speech, and vision are present in cerebrospinal sclerosis, 
but absent in paralysis agitans. 

Tumor of the pons or crus is accompanied with wild, jerky inco- 
ordination closely resembling disseminated sclerosis, but tumor also 
has headache, vomiting, optic neuritis, local spasm, and local 
paralysis. 

General paralysis of the insane and disseminated sclerosis are fre- 
quently confounded, as are locomotor ataxia and primary lateral 
sclerosis. 

Prognosis. Unfavorable. The disease slowly but steadily pro- 
gresses, chronic nephritis or tuberculosis frequently developing and 
causing death. 

Treatment. There is no drug having the power to cure sclerosis. 
Syphilis has been the cause of the vast majority, if not all, of the cases 
observed by the writer, and potassii iodidum, in large doses, or the 
following has seemed in a few instances to hold the disease in check 
for a time : 

B- Hydrargyri chloridi corros., . . gr. j .065 Gm. 

Liq. arsenici chloridi, f^j 4. Co. 

Inf. gentian., adf^iij ad 90. Cc. M. 

SiG. — Teaspoonful three times daily, in water. 

Attention to the general health and remedies to promote con- 
structive metamorphosis will prolong life and add to the comfort of 
the individual. 



474 PRACTICE OF MEDICINE. 



SYRINGOMYELIA. 

Synonym. Syringomyelitis. 

Definition. A chronic disease of the spinal cord, characterized 
by the formation of cavities in the substance of the cord, associated 
with loss of the perception of pain and temperature over certain 
regions, and complicated with muscular weakness and atrophy, and, 
at times, trophic changes. 

Causes. Not a frequent condition. Seen oftener in men than in 
women.' The etiological factors not determined. It is a disease of 
early life, beginning before thirty. 

Pathological Anatomy. There are present, a tubular cavity 
or cavities in the substance of the spinal cord. There is considerable 
difference of opinion as to how these cavities develop. It is thought 
that they may originate in either " a faulty closure of one of the 
divisions of the primary central canal of the cord, for in the course of 
development the primary central canal of the cord becomes divided 
into two parts — an anterior and a posterior. The anterior division 
forms the permanent central canal. The walls of the posterior divi- 
sion gradually come together and fbrm the posterior fissure. The 
imperfect closure of either of these divisions of the primary cen- 
tral canal may give rise to syringomyelia. Or, the abnormal 
cavity or cavities may depend on the disintegration of a gliomatous 
formation which originates generally in embryonal tissue about the 
central canal. The cavity varies in extent and location in different 
cases, so that it is possible to find marked evidences on autopsy 
which presented no symptoms during the lifetime of the individual. 
But usually the cervical cord is the seat of the disease. 

Symptoms. The condition develops slowly and insidiously, 
and nearly always bilaterally. There occur loss or diminution of 
the perception of temperature (heat and cold) and pain, the tactile 
se7ise being retained ; slowly developing muscular atrophy, due to 
involvement of the anterior horns of the cord. The atrophy usu- 
ally affects the arm and shoulder of one or both sides, and it may 
begin in the hand. Associated with the muscular atrophy is muscu- 
lar weakness and more or less fibrillary contractions. When the 
weakness involves the spinal muscles, scoliosis occurs. Arthro- 
pathies occur in many cases, particularly involving the shoulder- 



DISEASES OF THE NERVES. 475 

joint. Trophic changes also involve the skin, often advancing to 
ulceration and even gangrene, and rarely to painless felons, such as 
occur in Morvan's disease. 

The disease is seen in many irregular types, the loss of temperature 
sense in one part and the loss of sensation of pain in another, and 
other irregular distribution of the characteristic phenomena. 

The general health of patients suffer but little in syringomyelia. 

Diagnosis. Progressive muscular atrophy is apt to be confounded 
with syringomyelia unless the changes in the temperature and pain 
senses are remembered. Morvan's disease is by many neurologists 
classed as a variety of syringomyelia. 

Prognosis. Incurable, but of long duration ; often many years, 
with periods of quiescence. 

Treatment. Entirely symptomatic. 



DISEASES OF THE NERVES. 



SIMPLE NEURITIS. 

Definition. An inflammation of the nerve trunks ; characterized 
by pain, impaired sensation, motor paralysis, and atrophy. 

Causes. Wounds and injuries or compression of nerves ; cold 
and damp ; syphilis (?) ; lead. 

Pathological Anatomy. Hyperemia, followed by exudation 
into the nerve sheath and connective tissue, " which becomes softened 
and ultimately breaks down into a diffluent mass." Migration of 
white corpuscles takes place into the neurilemma. Recovery may 
occur before destruction of the nerve elements is produced, absorp- 
tion of the exudation occurring. " It is important to note that when 
inflammation occurs in a nerve it may extend from the point first 
diseased upward (neuritis ascendens) or downward {neuritis descen- 
dens)" 

Symptoms. The onset may be accompanied with febrile reac- 
tion. The most decided symptom is pain along the course of the 



476 PRACTICE OF MEDICINE. 

nerve trunk and its peripheral distribution, of a burning, tingling, 
tearing, intense character, increased by pressure or motion. If the 
affected nerve be a mixed one, — sensory and motor, — spasmodic con- 
tractions and muscular cramps occur, followed by impaired motion, 
terminating in paresis of the muscles innervated by the affected trunk. 
The sense of touch and of pain are markedly impaired, while the 
temperature and muscular sense are but slightly disturbed. 

If the inflammation proceed to destruction of the nerve trunk, wast- 
ing and degeneration of the muscular tissue ensues. Various trophic 
changes also occur, such as cutaneous eruptions and clubbing of the 
nails. The electro contractility is impaired or lost. 

Diagnosis. Myalgia or muscular pain is not associated with 
paralysis, nor does the pain follow the course of a nerve trunk. 

Neuralgia has the pain, but, as a rule, not the tenderness of neuritis. 

Prognosis. Generally favorable, with proper treatment. 

Treatment. Repeated blistering along the course of the nerve, 
preferably with the Paquelin cautery or a poker at white heat, with 
full doses of ftotassii iodidum, are usually successful. Sodii salicylas, 
phenacetin, and antifebrin are often valuable, but for severe pain no 
drug is to be compared with morphince sulphas by the hypodermic 
method. From the onset quinines sulphas, gr. ij-v (0.13-0.3 Gm.) 
every four hours, is most valuable, and if the attack be due to exposure 
to cold or damp, combine sodii salicylas, gr. ij-v (0.13-0.3 Gm.), in 
capsule. 

As the more acute symptoms subside, the use of galvanism or a 
feeble, slowly interrupted faradic current restores the disordered 
function of nerve and muscle. 

If anaemia be present, make use oiferrum, with malt and the hypo- 
phosphites. 

MULTIPLE NEURITIS. 

Synonyms. Polyneuritis ; peripheral neuritis ; disseminated 
neuritis ; degenerative neuritis ; pseudo-tabes ; alcoholic paralysis ; 
beri-beri (Brazil and India) ; kakke (Japan). 

Definition. A parenchymatous inflammation of a number of 
symmetrical peripheral nerves, simultaneously or in rapid succes- 
sion ; characterized by pain, numbness, loss of power, or ataxia, with 
muscular atrophy. Mental symptoms are often associated. 



DISEASES OF THE NERVES. 477 

Causes. Alcoholism ; syphilis ; malaria ; lead, arsenic, or silver ; 
following diphtheria, typhoid fever, and rheumatism. 

Beri beri and kakke are epidemic varieties of multiple neuritis, the 
result of a special poison. • 

The probability is that the various causes named develop in the 
blood a poison, having a particular susceptibility or " selective 
action " for nerve-fibres. 

Pathological Anatomy. The affection is generally bilateral 
and symmetrical. An important characteristic is its peripheral dis- 
tribution, the inflammation being most intense at the extremities of 
the nerves, lessening progressively toward the centre, usually termi- 
nating before the nerve roots are reached. The inflammatory process 
affects the nerve-fibres primarily and the sheath and connective-tissue 
secondarily — a parenchymatous inflammation. The affected muscles 
are paler and smaller than normal, the fibres reduced in size and 
undergoing granular changes. 

Symptoms. All plans yet suggested for classifying the varieties 
of multiple neuritis are imperfect. The onset may be sudden, even 
overwhelming, causing rapid death, but is usually subacute or 
chronic in its course, the symptoms being wide-spread in proportion 
to the acuteness, intensity, and cause of the malady. The symptoms 
may be described under three forms — a motor, a sensory, and an 
ataxic form. 

The motor form shows motor weakness, chiefly involving the 
flexors of the ankles, the extensors of the toes, and the extensors of 
the wrist and fingers in the forearms. . Inflammation of the anterior 
tibial or peroneal nerve in the leg, and the radial branch of the 
musculo-spiral in the arm, resulting in the double "foot-drop" 
and "wrist-drop" so characteristic of this disease. Any nerves of 
the body may be affected, the symptoms varying with the particular 
nerves. 

The sensory form shows pains, tenderness, tingling, and numbness 
with loss of cutaneous sensibility. 

At times the hypersesthesia of the extremities is so marked, and 
especially that of the soles of the feet and the muscles, that the slightest 
touch cannot be tolerated. 

The ataxic form shows inco-ordination with or without sensory 
disturbances, but with loss of the muscular sense. 

The forms may all be associated, in greater or less extent, in any 
one case. 



478 PRACTICE OF MEDICINE. 

Muscular atrophy begins early and progresses with the disease. 

The knee-jerk is feeble or absent. The electro-contractility is feeble 
or lost. 

In alcoholic cases, there may be delirium, mania, and delusions, 
associated with tremors. 

Foot-drop is a typical symptom in alcoholic neuritis. 

Trophic changes may occur in the nails, hair, and skin. The 
characteristic glossy condition of the skin, with some oedema, is due 
to involvement of the vaso-motor nerves. Rarely the vagus, optic, 
and laryngeal nerves are involved. 

The disease may be ushered in with fever, ioi° F.-103 F. ; rapid, 
feeble pulse ; headache, nausea, vomiting, with delirium or con- 
fusion. 

The alcoholic variety affects chiefly all the limbs, beginning in the 
flexors of the feet ; the malarial, the legs ; diphtheria, the pharyngeal 
and motors of the eye; rheumatic, the face; and lead, the arms. 

Beri-beri, or endemic neuritis, is an infectious form of multiple 
neuritis due undoubtedly to micro-organisms. It is claimed that some 
defect in diet is a predisposing cause of this variety. The symptoms 
and development are much the same as seen in other varieties with 
the addition of cedema and a tendency to effusions into the serous 
cavities and a cardiac involvement. In severe cases the pain is in- 
tense and the wasting rapid. 

Diagnosis. In no disease is an early diagnosis so important from 
a therapeutical standpoint. Early treatment may prevent months of 
suffering and idleness. 

Since the symptoms of this wide-spread affection have been prop- 
erly separated from diseases of the spinal cord, with which they 
were formerly always associated, the diagnosis is very readily deter- 
mined. 

Loss of power is an early symptom, usually beginning in the feet 
and extending upward so that multiple neuritis may be mistaken for 
Landry's paralysis. Ross considers these affections identical, but 
usually Landry's paralysis is a cord disease. 

Prognosis. As a rule, favorable if early and proper treatment be 
instituted. 

Treatment. Rest is of the greatest importance ; the more thor- 
oughly this is carried out, the better will be the results. 

Removal of the cause is an important indication. Warmth to the 






DISEASES OF THE NERVES. 479 

affected parts by flannel next to the skin, hot baths, and keeping the 
parts wrapped in cotton-wool. 

There is no specific drug for polyneuritis. For alcoholic cases use 
strychnines niiras ; for malarial cases, quinines sulphas ; for diphthe- 
ritic cases, tinctura ferri chloridi and strychnines sulphas ; for rheu- 
matic cases, sodii salicylas, salol, or phe?iacetin ; for syphilitic cases, 
hydrargyrum or potassii iodidiun ; for lead or other mineral poison 
cases, the iodides ; and in all varieties, tonics with a generous nutri- 
tious diet. 

Pain should be relieved with either antifebrin, or morphines sulphas, 
by the hypodermic method. As convalescence begins, moderate 
exercise and mild galvanism. Arsenicum is considered the best 
constructive tonic for the convalescence of multiple neuritis. 



NEURALGIA. 

Definition. A disease of the nervous system, manifesting itself 
by sudden pain of a sharp and darting character, mostly unilateral, 
following the course of the sensory nerves. 

Varieties. I. Neuralgia of the fifth nerve ; II. Cervico-occipital 
neuralgia; III. Cervico-brachial neuralgia ; IV. Dorso-intercostal 
neuralgia; V. Lumbo-abdominal neuralgia; VI. Sciatica; VII. 
Erythromelalgia (Mitchell). 

Causes. Hereditary. Anaemia ; malaria ; syphilis ; metallic poi- 
sons; anxiety; mental exertion; exposure to cold and damp; in- 
juries of a nerve trunk. 

Pathological Anatomy. The old axiom of neuralgia being 
" the cry of the nerves for pure blood" is perhaps only part of the 
truth. The changes in the nerve trunks or centres have not as yet 
been fully determined. A fair number of cases present the changes 
of neuritis. 

NEURALGIA OF THE FIFTH NERVE. 

Synonyms. Tic-douloureux ; Fothergill's disease. 

Symptoms. Paroxysmal pain, of a sharp, darting, stabbing 
character, most common at points along the course of the supra- and 
infra-orbital branches of the fifth nerve of the left side, attended with 
increased lacrymation. When of any duration, nutritive changes are 
observed in the nervous distribution, such as oedema along the course 
of the nerve, gray eyebrows, and co7ivulsive twitches of the muscles, 



480 PRACTICE OF MEDICINE. 

termed " tic-douloureux ," tenderness at the infra- and supra- orbital 
foramina, as well as along the course of the nerve distribution. 

CERVICO-OCCIPITAL NEURALGIA. 

Symptoms. Paroxysmal pain, of a sharp and lancinating, or 
deep, heavy, tensive character, along the course of the occipital nerve 
upon one or both sides, extending from the vertex, and on the neck 
as far down as the clavicle, and upward and forward to the cheek. 
May be associated with hypercesthesia of the skin, and with cramps'xn 
the cervical muscles, and with attacks of hejpes. A sensation of 
cracking at the nape of the neck is an annoying symptom in many 
cases. 

CERVICO-BRACHIAL NEURALGIA. 

Symptoms. Paroxysmal pain of a severe, boring, burning, or 
tensive character, with sensations of numbness and weakness of the 
arm, hand, shoulder, scapula, and mamma, with tenderness along the 
cervical plexus. (Edema of the arm and other parts along the dis- 
tribution of the cervical plexus occur if the neuralgia be of long dura- 
tion, the result of nutritive changes, the limb at times becoming pale, 
the skin glossy, dry, and harsh. 

DORSO-INTERCOSTAL NEURALGIA. 

Symptoms. Paroxysmal pain of a sharp, and lancinating char- 
acter, along the fifth and sixth intercostal spaces, often associated 
with the development of herpes, the so-called herpes zoster, or 
" shingles." 

Tenderness at the points where the nerves emerge from the inter- 
vertebral foramina at the sides of the chest and at points in front. 

LUMBO-ABDOMINAL NEURALGIA. 

Symptoms. Paroxysmal pain of a sharp and lancinating, at 
times heavy and dull, character, following the course of the ilio-hypo- 
gastric nerve, ilio-inguinal and external spermatic nerve, supplying 
the integument of the hip, the inner side of the thigh, the scrotum 
and labium. 

SCIATICA. 

Definition. A neuritis. Pain following the course of the sciatic 
nerve. The sacral plexus is made up of the fourth and fifth lumbar 
and the first two pairs of sacral nerves. 



DISEASES OF THE NERVES. 481 

Symptoms. Sciatica usually follows an attack of lumbago, the 
pain becoming fixed in the sciatic nerve ; at times it is a true neuritis. 

The pain is sharp, tearing, shooting, or lancinating in character, 
increased upon motion, shooting along the course of the nerve into 
the hip, inner side of the thigh, calf of the leg, ankle, and heel, at 
one or all of these points, in paroxysms lasting from a few hours to 
twenty-four hours or longer. The tactile sensation in the foot and 
motility in the limbs are impaired, and if of long duration, wasting 
of the limb occurs. 

ER YTH ROM ELALGI A . 

Synonyms. " Red neuralgia." 

Symptoms. This form of neuralgia was first described by Dr. 
S. Weir Mitchell. The feet principally, are affected by intense redness 
and burning pain. For a considerable period before the condition 
is typically developed there are aching pains in the feet, particularly 
when used. The feet, in Dr. Mitchell's own words, " get redder and 
redder, the veins stand out in a few minutes as if a ligature had been 
tied about the limb, and the arteries throb violently for a time, until 
at length the extremities become of a dark purplish tint." As a rule, 
the redness only occurs when the feet hang down, and when at rest 
they may be pale and perspire freely. Blisters and ulcers follow 
slight contusions of the feet. 

Diagnosis. Erythromelalgia has been confounded with Ray- 
naud's disease. The presence of pain, bright redness, throbbing, and 
increased temperature of the part are all the opposite of Raynaud's 
disease. 

PROGNOSIS OF NEURALGIAS. 

If promptly and properly treated, unless the result of pressure of 
an exostosis, aneurism, or other tumor, favorable, save for erythro- 
melalgia. 

TREATMENT. 

Rest ; easily assimilated but nutritious diet ; removal of the cause, 
if possible. If Rnzem\c,ferrum and arsenicum. If rheumatic, alka- 
lies and sodii salicylas. If syphilitic or the result of metallic poisons, 
potassii iodidum. If malarial, quinince sulphas, or hydrochloras. 

For an attack, morphi?ice sulphas and atropines sulphas, hypoder- 
mically, afford the most prompt and ready relief. 

Success usually follows the use of the well-known " Gross (Prof. S. 
D.) neuralgic pill " : 
41 



482 PRACTICE OF MEDICINE. 



Quinina; sulphat. , gr. ij 


.13 Gm 


Morphinse sulphat. , g r - 2*0 


.003 Gm 


Strychninse sulphat. , . . . . gr. 3^ 


.002 Gm 


Acidi arseniosi, gr. Jq 


.003 Gm 


Extracti aconiti, gr. \ 


.032 Gm 


Ft. pil. No j. 




SiG. — One every one, two, or three hours. 





Few attacks of trigeminal neuralgia will resist the following powerful 
prescription : 

R. Aconitinae (Duquesnel), . . . gr. -^ .006 Gm. 

Glycerini, 

Alcoholis, aa f ^j * aa 4. Cc. 

Aquae menth. pip., .... adfjjij ad 60. Cc. 

SiG. — Teaspoonful, repeated from four to eight times daily, carefully 
watching. 

For the pains of intercostal neuralgia, the following is recom- 
mended : 

R. Chloral, 3J 4. Gm. 

Pulv. camphorse, ^j 4. Gm. 

Menthol, £j 4. Gm. 

Mix and rub together. 

SiG. — Paint over painful parts with brush, p. r. n. 

Facial neuralgia is often wonderfully benefited by the internal 
administration of extraction gelsemii fluidum , rr^iij-v (0.2-0.3 Cc), 
every three or four hours until its physiological effects are produced; 
cannabis indica or belladonna may be combined with the gelsemium. 
Excellent results often follow the administration of Mousseltes pills 
(aconitine and quinine). 

For sciatica, antipyrin, gr. xx (1.3 Gm.), repeated two orthree times 
daily, has given relief, as hzsphenacetin and an life or in. The deep injec- 
tion of chloroformum is recommended by Bartholow. Nitro-glycer- 
inumhas been strongly recommended for sciatica, beginning with one 
drop of a one per centum solution three or four times a day and gradu- 
ally increasing the dose until four or five drops several times daily 
are taken. Dr. Mitchell is a strong advocate of the application of a 
flannel bandage for the entire leg, changed daily, and a splint reach- 
ing from the axilla to the heel, held loosely to the limb, and tonics. 
Rarely, he uses cocaines hydrochloras gr. \ (0.016 Gm.) hypodermically 
over a painful spot. A spray of chloride of methyl along the course 



DISEASES OF THE NERVES. 483 

of the nerve for a few moments, watching the skin, will relieve the 
distressing pain. Rarely, full doses of potassii iodidum with a blister 
along the course of the nerve gives relief. 

For erythromelalgia all drug treatment has failed to cure. Rest 
and elevation of the limb gives relief. Dr. Mitchell recommends 
either nerve stretching, and in aggravated cases nerve excision, 

All forms of neuralgia are more or less benefited with — 

R. Quininae sulph., gr. iij .2 Gm. 

Ferri reduct, ........ gr. j .065 Gm. 

Acid, arseniosi, gr. ^o -°°3 Gm. 

Aconitiae, gr. T |^ .00054 Gm. 

In pill, every four or five hours. 



FACIAL PARALYSIS. 

■?', 

Synonym. Bell's palsy. 

Definition. An acute paralysis of the seventh cranial, — the facial 
nerve, the great motor nerve of the muscles of the face, — the nerve 
of expression. 

Causes. Exposure to a current of cold air against the side of the 
face — over the pes anserinus — is the most frequent cause. Also due 
to injury or disease of the middle ear. Syphilis. 

Symptoms. The facial nerve supplies the muscles of the face, 
the muscles of the external ear, also the stylo-hyoid, posterior belly of 
the digastric, the platysma, one muscle of the middle ear, the stape- 
dius, and one palate muscle, the levator palati ; by means of the 
chorda tympani branch it controls the secretion of the parotid and 
submaxillary glands, and, possibly, the sense of taste. It also 
furnishes motor power to the azygos uvulae, the tensor tympani, and 
the tensor palati muscles. 

The onset is usually sudden, with tingling of the lips a?id tongue, 
and upon looking into the mirror the patient is surprised by the per- 
fectly blank, motionless side of his face ; the corner of the mouth is 
depressed, the eyelids open, the face drawn toward the well side, and 
the patient is unable to expectorate, whistle, or swallow. 

Any of the muscles innervated by the nerve may participate in the 
paresis. 

The electro- contractility is feeble or lost. The reflexes are abolished. 



484 PRACTICE OF MEDICINE. 

Diagnosis. Paralysis of the muscles of the face occurs in hemi- 
plegia ; the .points of differentiation are the presence of cerebral 
symptoms and the normal reflex excitability. 

Facial palsy with otorrhoea, imperfect hearing, obliquity of the 
uvula, and loss of taste determine its origin within the aquaeductus 
Fallopii. 

It is due to peripheral neuritis if the taste be normal and the uvula 
straight. 

If other nerves are also involved, the origin is central. 

Prognosis. Favorable. 

Treatment. If the result of cold and damp, diaphoresis with 
pilocarpus, or diuresis with potassii acetas, vel iodidum, and blisters 
in front of the ear, and the use of galvanism to the affected muscles. 



GENERAL OR NUTRITIONAL DISEASES. 



CHOREA. 



Synonyms. St. Vitus' dance ; insanity of the muscles. 

Definition. A functional (?) disorder of the nervous system; 
characterized by irregular spasmodic fibrillary movements of groups 
of muscles, with muscular weakness, more or less approaching paral- 
ysis of the affected parts. 

Causes. Essentially a disease of childhood ; hereditary ; reflex, 
from dentition, worms, masturbation, or fright; probably the result 
of rheumatism in many cases. 

Pathological Anatomy. As yet there has been no constant 
anatomical lesion discovered, the theory of emboli having, however, 
many advocates. 

Symptoms. The onset is usually gradual, the child seemingly 
grimacing or jerking the arm or hand, as if in imitation, followed soon 
by decided irregular jactitations of the muscles of the face (histrionic 
spasm), of the eyelids (blepharospasm), eyeballs (nystagmus), and 
the shoulder, arm, and hand, finally extending to the lower extremi- 



GENERAL OR NUTRITIONAL DISEASES. 485 

ties, interfering with motility ; in severe cases, inability of self-feeding 
or of holding anything in the hands. The speech is often unintelli- 
gible, the tongue constantly moving in an irregular manner. 

The heart's action is tumultuous and irregular, associated often with 
a soft, blowing, systolic murmur, most distinct at the base. The 
muscles are usually quiet during sleep, although this is not always 
the case. The mind is somewhat blunted, the temper irritable, the 
memory impaired. If the irregular muscular movements are con- 
fined to one side of the body, it is termed hemi-chorea. 

Diagnosis. Chorea was confounded with epilepsy until the points 
of distinction were pointed out by Sydenham. 

Huntington' s or chronic chorea is distinctly hereditary, and, instead 
of being fibrillary contraction of muscles, involves whole groups of 
muscles, so that the patient seems to be posturing and grimacing, 
with a dancing movement, with many queer contortions of the face 
and head. Generally, all the muscles of the body are involved. It 
may have associated the fibrillary muscular contractions of St. Vitus' 
dance. 

Paralysis agitans has general muscular tremor, beginning in one 
limb, gradually progressing, uninfluenced by treatment ; a disease of 
the elderly. 

Post-hemiplegic chorea is the choreic movement of a paralyzed 
limb. 

Prognosis. The vast majority of cases recover, but relapses are 
very frequent. 

Treatment. Remove the cause, if possible. Easily assimilated 
diet. Many cases improve rapidly by confinement to bed in a dark- 
ened room. If the muscular movements interfere with sleep, mor- 
phines sulphas or chloral are indicated. Regulate the secretions. 

Arse7iicum is the most reliable remedy yet introduced for the treat- 
ment of chorea. It should be pushed to its first physiological effects, 
then gradually reducing the dose until all symptoms disappear. The 
form of the remedy best adapted for administration in this disease is 
liquor potassii arsenilis, T^v (0.3 Cc), increased to tt\,x (0.6 Cc), or 
even Ti\,xv (i Cc), three times a day. Extractum cijnicifugcs fluidum, 
rr\,xx-f3j (1.3-4 Cc), t. d., is serviceable, especially in cases following a 
rheumatic attack. Cases resisting the arsenicum treatment may rapidly 
improve under hyoscya?ninincs hydrobromas, gr. u^j-xotj (0.00032- 
0.00065 Gm.), three times daily. A patient of mine, aged sixtsen 



486 PRACTICE OF MEDICINE. 

years, who resisted all the remedies mentioned, was promptly cured by 
antipyrin, gr. x (0.6 Gm.), four times daily. This same lad had a 
former attack arrested by morphine? sulphas, gr. % (0.016 Gm.), four 
times daily, but this latter remedy failed in the attack controlled by 
the antipyrin. If anaemia be present, combine or alternate arsenicum 
with ferrum. Wood recommends quinince sulphas. 



EPILEPSY. 

Definition. A chronic disease, of which the characteristic symp- 
toms are a sudden loss of consciousness, attended with more or less 
general convulsions. 

Causes. True epilepsy almost always first arises during the growth 
and development of the brain. Heredity. Rarely, worry, anxiety, 
depression, or fright. Pressure from a tumor at the periphery, or 
thickening of the membranes of the brain causing pressure; 
syphilis; uterine diseases. 

Pathological Anatomy. There are no constant anatomical 
lesions, as yet, associated with essential epilepsy. 

In " Jacksonian," "cortical," or " partial epilepsy," however, the 
"motor cortex" is irritated by disease and there occur tonic and 
clonic spasms of the same character as in general epilepsy, confined 
to a single arm, or an arm and half the face together, or may be the 
entire half of the body. These epileptiform attacks furnish precise 
data as to the locality of the lesion ; spasms affecting the distribution 
of the facial nerve point to the lower third of the central convolution ; 
of the arm, the middle third of the central convolution; of the lower 
extremity, the upper third of the central convolution. 

Varieties. I. Epilepsia gravior, le grand mal ; II. Epilepsia 
mitior, le petit mal. 

Symptoms. Le grand mal \s preceded by a more or less pro- 
nounced and curious sensation, the so-called aura epileptica. 

The attack proper is sudden, the subject suddenly falling, with a 
peculiar cry, loss of consciousness, and pallor of the face, the body 
assuming a position of teta?iic rigidity, succeeded after a few mo- 
ments by more or less pronounced clonic convulsions followed by 
coma of several hours' duration. The subject awakens with a con- 
fused or sheepish expression, with no knowledge of what has 



GENERAL OR NUTRITIONAL DISEASES. 487 

occurred, unless he has injured himself during the attack, either by 
the fall, or, what is very common, has bitten his tongue during the 
convulsions. 

Le petit mat is manifested either by attacks of vertigo, the con- 
sciousness being preserved, or by a passing absent-mindedness, either 
form being associated with slight convulsive phenomena followed by 
slight coma or mental confusion of short duration. 

The mental functions are not, as a rule, injured by attacks of epi- 
lepsy, unless they recur very frequently. Indeed, when at wide 
intervals, the subject seems relieved by them, " the sudden, excessive, 
and rapid discharge of gray matter of some part of the brain on the 
muscles," the so-called " electrical storm," having cleared the cere- 
bral atmosphere. 

The great majority of epileptics suffer from chronic gastric catarrh, 
and have at the same time an inordinate appetite (boulimia) ; indeed, 
an attack of gluttony may immediately precede a fit. 

Epileptics are very liable to the development of tuberculosis and 
of nephritis. 

Diagnosis. Ur&mic convulsions closely resemble an epileptic 
attack ; but the dropsy or general oedema and albuminous urine, 
and increased temperature of the former should guard against error. 

Feigned epilepsy often misleads the most practical expert. 

Jacksonian epilepsy begins as a spasm of a limb or some portion 
of a limb, and is confined there or may gradually extend until even a 
general convulsion occurs. 

Prognosis. The vast majority of cases will not recover under 
treatment, but have the frequency and severity of the attacks greatly 
ameliorated, but sooner or later returning with their former severity. 
Cases the result of the various reflex causes usually recover when the 
cause is removed. 

Treatment. To avert an impending attack, inhalations of amyl 
nitris, rr^iij-v (0.2-0.3 Cc), a few whiffs of chloroformum, or the hypo- 
dermic injection of jnorfihince sulphas. 

To prevent the return of attacks, remove the cause if possible, and 
attention to the secretions and the internal administration of potassii 
bromidum, in doses sufficient to abolish the faucial reflex and produce 
the symptoms of bromism, have great power in diminishing the 
severity and frequency of the attacks; better results are sometimes 
obtained bv the combination of the various bromides. Cases in which 



488 PRACTICE OF MEDICINE. 

the bromides are not serviceable are sometimes benefited by argenti 
nitras, belladonna, or cannabis indica, but such cases are rare. 
Weak and anaemic subjects usually do better with strychnina in full 
doses than with potassii bromidum. If a history of syphilis can be 
obtained, the combination of potassii iodidum and potassii broniidum, 
will effect a cure. 

Whichever of the above remedies is beneficial in any particular 
case, the permanency of the relief can only be maintained by the con- 
tinuation of the drug for at least two years after the last attack. 

Gowers highly recommends the following in cases complicated 
with cardiac dilatation : 

R. Potassii bromidi, gr. xx 1. 3 Gm. 

Tinct. digitalis, W\x .6 Cc. 

SiG. — Three times a day, well diluted. 

The following is the combination used in the insane wards of the 
Philadelphia Hospital : 

R . Sodii bromidi, 

Potassii bromidi, aa £iv aa 16. Gm. 

Liq. potassii arsenitis, f^iss 6. Cc. 

Aquae menthse pip., f.^iij Q°« Cc. 

Inf. gentian, comp. , . q. s. adf^viij ad 240. Cc. 
SiG. — Tablespoonful, diluted, three times daily. 

Brown-Sequard's mixture for epilepsy is as follows : 

R. Potassii iodidi, 8 parts. 

Potassii bromidi, 8 " 

Ammonii bromidi, 4 " 

Potassii bicarb., 5 " 

Inf. columbo, 360 " 

SiG. — One teaspoonful before meals, and three dessertspoonfuls on going to 

bed. 

The following is an effective combination for the " mixed bro- 
mides " : 

li . Sodii bromidi, 5jj 30. Gm. 

Potassii bromidi, 3 vss 22. Gm. 

Ammonii bromidi, B y iij IO -6 Gm. 

Potassii bicarb., % ij 8. Gm. 

Inf. columbo, f ^ x 300. Cc. 

Aq. chloroformi, . . q. s. ad Oj ad 480. Cc. M. 

SiG. — Tablespoonful equals gr. xxx (2 Gm.). 



GENERAL OR NUTRITIONAL DISEASES. 489 

Status epilepticus is always a dangerous condition, and efforts to 
prevent it should be made by active medication the moment a series 
or group of fits occur. The following combinations sometimes are 
wonderfully successful in aborting the status : 

R . Chloral, gr. xxx 2. Gm. 

Tinct. cannab. indicse, .... ttlxv I. Cc. 

Infus. digitalis, f^j 30. Cc. M. 

Sig. — By high enema, repeated if indicated in two or three hours. 

Dr. Spratling, Craig'Epileptrc Colony, recommends : 

R. Tinct. opii deodorat., .... TTlv .3 Cc. 

Potassii bromidi, .' gr. xxx 2. Gm. 

Chloral, gr. xx 1.3 Gm. 

Liq morph. (U. S.), TTljss .09 Cc. 

Aquae, f^ss 15. Cc. M. 

SiG. — By mouth, or, if cannot swallow, by en^ma. 

A hypodermic injection of morphines sulphas, gr. y$ (0.02 Gm.), 
and atropines sulphas, gr. -^ (0.00 1 Gm.), has sometimes broken up a 
series of epileptic spasms. 

The diet of the epileptic must be carefully regulated — meats, tea, 
and coffee excluded, or used in very moderate amounts. Forbid 
tobacco and alcohol. 

Much enthusiasm is reported in the important results following tre- 
phining in cases of Jacksonian epilepsy. It is to be hoped success 
will follow this operation, but the subject is still subjudice. 

" The surgical treatment of epilepsy has been extensively employed, 
but it is distinctly disappointing, for, while almost any operation may 
benefit a patient for a time, there is no operation which will certainly 
cure" (J. Chalmers Da Costa). 



HYSTERIA. 

Definition. A nutritional disorder of the nervous system, of the 
nature of which it is impossible to speak definitely ; characterized by 
disturbances of the will, reason, imagination, and the emotions, as 
well as motor and sensory disturbances. 

Causes. A morbid condition confined principally to women. 
Young girls, old maids, widows, and childless married women are 
the most frequent subjects of the disorder. The paroxysms frequently 
42 



490 PRACTICE OF MEDICINE. 

develop during the menstrual epoch. The menopause is another 
frequent period for its manifestation. A peculiar condition of the 
nervous system, either inherited or acquired, is responsible for the 
phenomena of hysteria, the peculiar manifestations being excited by 
disturbances of either the sexual, digestive, circulatory, or nervous 
systems. 

Hypochondriasis, a peculiar mental condition, characterized by 
inordinate attention on the part of the patient to some real or sup- 
posed bodily ailment or sensation. A continual introspection, as 
seen in males, is a condition much like the hysteria of the female. 

Pathogeny. Structural alterations having thus far not been de- 
tected in cases of hysteria, it is classed as a functional disturbance of 
the nervous system. It should, however, be borne in mind that 
hysterical manifestations frequently develop during the prevalence 
of organic diseases. 

Symptoms. These will be considered under the headings of the 
hysterical paroxys?n, and the hysterical state. 

The Hysterical Paroxysm or fit occurs nearly always in the pres- 
ence of others, and develops gradually with sighing, meaningless 
laughter, causeless moaning, nonsensical talking, and gesticulations, 
or a condition oi fidgets followed with a sensation of choking, dyspncea, 
and a ball in the throat — the globus hystericus. These and similar 
symptoms precede the fit, during which the unconsciousness is only 
apparejit, the patient being aware of what is transpiring about her. 
During the paroxysm the patients may struggle violently, throwing 
themselves about, their thumbs turned in and their hands clenched. 
Again, spasmodic movements occur, varying from slight twitching in 
the limbs to powerful general convulsive movements, and to almost 
tetanic spasms. 

The paroxysm ends by sighing, laughing, crying, and yawning, 
and a sensation of exhaustion. During the attack it will be noted 
that the surface and face are normal, showing absence of respiratory 
embarrassment, the breathing varying from very quiet to spluttering 
and gurgling sounds, the pupils not dilated, the pulse normal, the 
temperature normal, and absence of foaming at the mouth and 
wounding of the tongue. 

The Hysterical State is shown by disturbances of the mental and 
sensory-motor functions respectively. It may be a permanent condi- 
tion or occur at intervals with greater or less severity. 






GENERAL OR NUTRITIONAL DISEASES. 491 

Mental disturbances. The patients are emotional, erratic, excitable, 
impatient, and self-important, showing marked defects of will and 
mental power. 

Sensory disturbances. This is either a condition of exaggerated 
sensibility or hyperesthesia, as shown by the marked effects from the 
slightest irritation and the cutaneous tenderness along the spine, or a 
condition of anaesthesia, as shown by the apparent absence or recogni- 
tion of pain after severe irritation, or a perverted sensibility, as shown 
by the feeling of tingling, numbness, and formication. Sensibility to 
heat or cold are often absent. There is great perversion of the special 
senses in many of the cases. 

Charcot, referring to the ovarian hyperesthesia of hysteria, says : 
" It is indicated by pain in the lower part of the abdomen, usually 
felt on one side, especially the left, but sometimes on both, and occu- 
pying the extreme limits of the hypogastric region. It may be 
extremely acute, the patient not tolerating the slightest touch ; but in 
other cases pressure is necessary to bring it out. The ovary may be 
felt to be tumefied and enlarged. When the condition is unilateral, 
it may be accompanied with hemianesthesia, paresis, or contracture 
on the same side as the ovarialgia ; if it is bilateral, these phenomena 
also become bilateral. Pressure upon the ovary brings out certain 
sensations which constitute the aura hysterica, but firm and systematic 
compression has frequently a decisive effect upon the hysterical con- 
vulsive attack, the intensity of which it can diminish, and even the 
cessation of which it may sometimes determine, though it has no 
effect upon the permanent symptoms of hysteria." 

Motor disturbances. These phenomena embrace every variety of 
motor disturbance, from exaggerated excitable movements to defect- 
ive or complete loss of power. With the paralysis that may occur, 
neither nutrition nor sensation is constantly impaired. Hysterical 
paralysis is liable to frequent and sudden changes, the loss of power 
often disappearing suddenly. Hysterical contractures often are most 
extensive and persistent. Under some emotion or unknown cause a 
group or groups of muscles contract abruptly or by degrees, the 
spasms involving flexors or extensors or both with changes in reflexes, 
and lasting for days or years. Aphonia, from paralysis of the laryn- 
geal muscles, is a frequent form of paresis. Some hysterical patients 
refuse to even make an attempt at speech (mutism). 

"A curious enlargement of the abdomen is observed sometimes, 



492 PRACTICE OF MEDICINE. 

constituting the so-called phantom tumor. This region presents a 
symmetrical prominence in front, often of large size, with a constric- 
tion below the margin of the thorax and above the pubes. The 
enlargement is quite smooth and uniform, soft, very mobile as a whole 
from side to side, resonant, but variable on percussion, and not pain- 
ful. Vaginal examination gives negative results, and under chloro- 
form the prominence immediately subsides, returning again as the 
patient regains consciousness. 

Among the numerous other symptoms that may develop in a hys- 
terical patient are disturbances of digestion, circulation, respiration, 
and disorders of micturition and menstruation. 

Among other phenomena that belong to the Hysterical State are 
to be mentioned Hystero-epilepsy, a condition of hysteria to which is 
superadded the convulsion, epileptic in form. Catalepsy, a condition 
in which the will seems to be cut off from certain muscles, and in 
whatever position the affected member is placed, it will so remain for 
an indefinite time. There may or may not be unconsciousness and 
loss of sensation. Trance, the individual lying as if dead, circulation 
and respiration having almost ceased. Ecstasy, a condition in which 
the individual pretends to see visions, and acts in a most ridiculous 
manner. 

Diagnosis. The hysterical state is so general in its manifesta- 
tions that it is to be borne in mind in diagnosing all ailments occurring 
in women. The diagnosis is attended with great difficulty, however, and 
requires the display of all the skill of the clinician to prevent error. 

Prognosis. Death from either a hysterical fit or the hysterical 
state is the rarest of events, if it ever occur. The ultimate recovery 
of a hysterical patient is of frequent occurrence. Marriage has cured 
many cases, although it can hardly be advised by the physician. 

Treatment. For the hysterical fit little need be done, as a rule, 
unless the paroxysm is violent or prolonged, in which case ammonii 
valerianas, Hoffman s anodyne, or spiritus ammonia aromaticus, may 
be administered. Charcot recommends the making of firm pressure 
over the ovarian region to check hysterical fits that are of a severe 
character. 

The management of a confirmed case of hysteria will tax the skill 
of the most astute physician. It is in connection with hysteria that 
the peculiar phenomena supposed to arise from applying different 
metals to the surface of the body have been noticed. 



GENERAL OR NUTRITIONAL DISEASES. 493 

Moral and hygienic measures are of the first importance in the 
management of hysterical patients. The treatment by isolation of 
hysterical patients is strongly urged by many specialists. Dr. S. 
Weir Mitchell has devised a plan for bedfast hysterical patients, of 
massage, faradization, and forced feeding, which has been successful 
in a number of cases. 

There is no fixed therapeutical treatment for hysteria, the various 
symptoms calling for interference as they arise. It is well, however, 
to avoid the use of stimulants, opiates, chloral, and other nervous 
sedatives. 

NEURASTHENIA. 

Synonyms. Spinal irritation ; nervous prostration ; nervous ex- 
haustion. 

Definition. A debility of the nervous system, causing an inability 
or lessened desire to perform or attend to the various duties or occu- 
pations of the individual. 

Prof. Bartholow describes it as consisting " essentially in an exag- 
gerated susceptibility to bodily impressions and false reasoning 
thereon." 

Causes. Heredity. It may result from various chronic diseases ; 
mental worry or emotion ; overwork, as " whenever the expenditure 
of nerve-force is greater than the daily income, physical bankruptcy 
sooner or later results " (Jackson). Neurotic temperament ; sexual 
excesses; alcohol; tobacco. 

Symptoms. Nervous debility may affect any organ of the body. 
It is a condition of nerve-tire or exhaustion, and hence the nervous 
energy necessary for functional activity of any particular organ may 
be wanting, a fair example being seen in cases of nervous dyspepsia. 

One of the earliest manifestations of nervous exhaustion is an irri- 
tability or weakness of the mental faculties, as shown by inability to 
concentrate the thoughts, and efforts to do so causing headache, ver- 
tigo, restlessness, fear, a feeling of weariness and depression, together 
with the army of symptoms attendant on nervousness. 

There may be ocular disturbances, cardiac palpitation, coldness 
of the hands and feet, chilliness followed by flashes of heat, followed 
in turn by slight sweating. Patients are troubled with insomnia, or 
fatiguing sleep, accompanied with unpleasant dreams. 



494 PRACTICE OF MEDICINE. 

In the male there are genito-urinary disorders, with pains in the 
back, giving the dread of impotence. In females, painful menstrua- 
tion, ovarian irritation, and irritable uterus. 

The " neurasthenic stigmata " are : Feeling of pressure on head ; 
disturbance of sleep ; pain in back ; muscular weakness ; dyspepsia ; 
sexual disturbances and mental disturbances. 

Diagnosis. It is of importance to determine between a true ner- 
vous exhaustion and nervous debility the result of organic disease. 
A study of the history of the case, together with the symptoms, should 
prevent error. 

Neurasthenic symptoms in puberty are strongly indicative of mental 
instability, and great care must be exercised to prevent actual insanity 
from developing. 

Prognosis. Usually some mental weakness remains after re- 
covery from an attack of neurasthenia. 

Treatment. The physician should remember that neurasthenia 
is not a disease per se, but that the victim is a sick individual needing 
the best environment, rest, and good food. Attention to the secretions, 
diet, and surroundings. Rest and diversion of the mind are essential 
to success. Travel, short of fatigue, pleasant companionship, and 
relief from responsibility. Bathing, massage, and galvanism are im- 
portant aids in the management. 

Among the internal remedies that are of value may be mentioned, 
arsenicum, strychnin a, ferrtcm, zitici valerianas, phosphorus, ex- 
tractum cocce fluidum, vinum coccb, and syrupus hypophosphitis 
compositus. Quinines sulphas, in small doses, gr. i-ij (0.065-0.13 
Gm.), daily, for weeks, seems to lessen the excitability of the nervous 
system. 

The following is an excellent neurasthenic tonic : 



li . Acid, phosphoric, dil., 
Ext. cocas fid. , . . . 
Tinct. nucis vomicae, 
Syr. zingiberis, . . . 
Aqua? menthae pip., 
SiG. — Tablespoon ful after meals, in water. 



.f 3 ij 8. Cc. 

. fgvj 24. Cc. 

. f % ij 8. Cc. 

. f^iss 45. Cc. 

f?vi ad 180. Cc. M. 






GENERAL OR NUTRITIONAL DISEASES. 495 



EXOPHTHALMIC GOITRE. 

Synonyms. Graves' disease ; Basedow's disease. 

Definition. A disease of the nervous system ; characterized by 
protrusion of the eyeballs, enlargement of the thyroid gland, dilata- 
tion of the arteries, and palpitation of the heart. 

Causes. An undemonstrable condition of the nervous system, 
either inherited or acquired, is the predisposing cause of Graves' 
disease. Among the exciting causes are anaemia, shock, fright, 
chagrin, worry, and reverses of fortune. 

It is more frequent in women than in men. 

Pathological Anatomy. " Some structural alterations have 
been found, in a majority of cases, in the sympathetic ganglia, and 
especially in the inferior ganglia." (Bartholow.) The veins and 
arteries of the thyroid gland are dilated, the result of a vasomotor 
paralysis. The enlargement of the gland is the result of the dilated 
vessels, and a serous infiltration of its tissues, followed, if long con- 
tinued, by hypertrophy. A considerable increase of fat behind the 
eyeballs has been observed. In the majority of cases more or less 
anaemia exists. 

Symptoms. The development of the quaternary of symptoms 
may occur suddenly, the result of some great shock to the nervous 
system, but in the majority of instances the symptoms develop slowly 
and insidiously, with cardiac palpitation, with paroxysms of more 
marked acceleration, or tachycardia, the pulse-rate varying from 90 to 
120, 150, and rarely as high as 200 beats per minute ; soon pulsations 
of the vessels of the neck and thyroid gland may be felt and seen. 
The enlargement of the thyroid gland — the goitre — appears gradually 
after the development of the circulatory disturbances, although rarely 
it may be the first symptom observed. The goitre is elastic, rather 
soft, and has a thrill similar to an aneurism. The degree of enlarge- 
ment varies in different cases, and in none ever attains a very great 
size. Following the development of the goitre occurs the protrusion 
of the eyeball, — the exophthalmos, — which may be confined to one 
eye, but usually occurs in both. Prominence of the eyeball may be 
the first symptom observed, but usually it does not develop until after 
the appearance of the goitre. The degree of protrusion varies from 
a slight staring expression to a point so great that the eyelids cannot 



496 PRACTICE OF MEDICINE. 

cover the balls. Associated with the protrusion of the eyeballs is 
inco-ordination in the movements of the eyelids and the eyeball, the 
sign of Graefe, so that when the eyes are quickly cast down, the eye- 
lids do not follow them, the sclerotic being visible below the upper lid. 
Vision is unimpaired. Conjunctivitis may arise, the result of the im- 
perfect protection of the protruding ball by the eyelids. 

Associated with the pathognomonic symptoms are nervousness, 
irritability of temper, headache, insomnia, vertigo, fits of despondency, 
aphonia, and cough the result of pressure of the goitre, disorders of 
digestion, increase of temperature, anaemia, and loss of flesh. 

Diagnosis. The fully developed disease presents no difficulties 
in diagnosis, but during its incipiency, before the characteristic symp- 
toms have appeared, the disease may be confounded with such condi- 
tions as cardiac disease, neurasthenia, lithaemia, malaria, or incipient 
phthisis. 

Prognosis. Recovery occurs in a fair number, but is slow 
and tedious. The disorders of the circulation lead to dilated heart in 
many cases, and ultimately death occurs from this cause. Relapses 
are frequent. 

Treatment. One of the first injunctions to be placed on a case 
of exophthalmic goitre is rest, both physical and mental, as well as 
freedom from worry or emotional excitement; little progress will be 
made if this point be neglected. The general nervousness, restless- 
ness, and insomnia will often call for special treatment, when use may 
be made of chloral, potassii bromidum, sulphonal, or trional. It is 
better, however, not to use this class of drugs in a routine manner, 
but for the special indications only. 

The chief indication next to rest is the condition of the circulation. 
To control this, two remedies are of inestimable value ; they are 
digitalis and strophanthus. The results I have seen from tinctura 
strophanthus, Try,v (0.3 Cc), from three to six times daily, have been 
most satisfactory. Dr. Bartholow " has had good effects from quinina, 
belladonna, and ergotin in combination." I have had complete and 
quite rapid recovery in three pronounced cases from dried extract of 
thyroid gland in three grain doses (0.2 Gm.) twice and thrice daily. 
Always begin the use of the preparations of thyroid gland with very 
small doses, gradually increasing as required. Argenti nitras, gr. % 
(0.008 Gm.), after meals, is often a valuable remedy, alternating with 
strophanthus or digitalis. 



GENERAL OR NUTRITIONAL DISEASES. 497 

The associated anaemia is to be treated by ferrum, arsenicum, and 
an easily digestible and nutritious diet. Galvanism to the cervical 
sympathetic and pneumogastric is an important adjuvant to the 
medicinal treatment. 

Surgical treatment has been strongly urged for the cure of exoph- 
thalmic goitre. DaCosta (J. Chalmers), after reviewing the literature 
of such operations, concludes : " Treat most cases medically and by 
rest; if medical treatment fails, consider the advisability of surgical 
treatment. Surgical treatment is not certainly curative, and is dan- 
gerous." 

TETANY. 

Synonyms. Tetanilla ; intermittent tetanus. 

Definition. A succession of tonic, usually bilateral, painful mus- 
cular spasms, occurring at irregular intervals, without loss of con- 
sciousness. 

Causes. Unknown. Probably a special germ. It has been 
observed in those having a family history of nervous disorders. 

Pathology. The disease is very rare in America, and no lesion 
has as yet been determined. 

Symptoms. Tetany is the occurrence of intermittent spasms in 
the muscles of the arms, hands, legs, or feet, or, rarely, the face and 
larynx (laryngismus stridulus), associated with. flain or "cramp." 

The hands are thrown into a position such as they assume in writ- 
ing, or such as is taken by the hand of a midwife ; or the hand may 
be tightly closed, or one or more fingers may be cramped. The 
elbows and shoulders may be, at times, affected. In the feet the toes 
are drawn down and the instep upward, itfe^in equinus. The knees 
may be cramped or the legs extended. 

Any muscles may be involved. Trousseau pointed out that in those 
suffering from tetany, pressure upon the affected extremities at certain 
points will excite the spasms. 

The duration of the spasm varies from a few moments to several 
hours, the intervals being from an hour to a day or more. A certain 
periodicity is noticed as to the hour of the day or night. 

The electro-contractility is increased, as are also the reflexes. Erb 
first described the peculiar galvanic exaltation found in this disease. 

The consciousness is always preserved, although the patients are 
very nervous. 



498 PRACTICE OF MEDICINE. 

Diagnosis. Tetanus and tetany may be confounded, and yet 
trismus is rare in the latter, and always present in the former. 

Prognosis. Favorable. 

Treatment. Attention to the secretions and excretions, and the 
use of potassii bromidum, gr. xx-xl (1.3-2.6 Gm.), well diluted, three 
times daily. 

Gowers recommends digitalis for nocturnal tetany — those painful 
cramps in the calves in the early morning hours. Urethan, gr. x 
(0.6 Gm.), every three or four hours, is highly spoken of. Gray "says : 
" Cold to the extremities and ice to the spine have an excellent 
effect." 



TETANUS. 

Synonyms. Lockjaw; trismus; cephalic tetanus. 

Definition. An acute or subacute infectious disease, characterized 
by muscular rigidity, with paroxysms of tonic convulsions, the mind 
remaining clear. 

Idiopathic tetanus when no open wound is discoverable. 

Traumatic tetanus when an open wound is present. 

Tetanus neonatorum when it attacks infants. 

Lockjaw or trismus when the jaw alone is involved. 

Cephalic tetanus when the throat and face are affected. 

Causes. The result of a specific bacillus, which usually gains 
access to the system through an abrasion. 

Pathological Anatomy. In the post-mortem examinations 
which have been made, no uniform morbid appearance was dis- 
covered on microscopical examination. 

The brain, cord, lungs, and muscles are markedly congested, and 
show minute hemorrhages, such as are met with in all cases of death 
from convulsions, and which occur chiefly during the process of 
death. 

In four post-mortem examinations of cases dying from tetanus at 
the Philadelphia Hospital, marked chronic nephritis was observed. 
Probably the future may show some connection between nephritis 
and tetanus, by which the specific poison is not eliminated as it might 
be were the kidneys normal. 

Symptoms. The onset is rather sudden, with stiffness of the jaw, 
neck, and tongue, and some difficulty in swallowing, which increases 



GENERAL OR NUTRITIONAL DISEASES. 499 

in extent, the stiffness passing down the spinal muscles to the legs, 
which are held in a firm spasm. 

Gradually tonic spasms develop, which, involving the jaw muscles, 
cause " lockjaw " ; the face muscles, " risus sardonicus " ; neck and 
trunk muscles, "opisthotonos " ; these tonic convulsions are associated 
with intense pain, and the patient suffers the greatest distress, particu- 
larly if the chest muscles are involved. Usually the febrile reaction 
is slight, but in many cases 102 F.to 104 F. is reached, and in some 
instances, as death approaches, 108 F. to no° F. may occur, rising 
still higher after death. The mind remains clear till carbonic acid 
poisoning occurs. Usually a wound, not severe, can be found, the 
symptoms developing some two weeks after its occurrence. 

The tonic spasms are developed by any sources of irritation, a 
draught of air, shaking of the bed or floor, suddenly opening the door 
of the room, the presence of a visitor, or attempts at speaking or 
movement. 

Diagnosis. The symptoms are so characteristic, with the addi- 
tion of a history of a wound, that an error seems hardly probable. 

Tetany. The spasms chiefly affect the extremities, the muscles 
being free in the interval and trismus a late or very rare condition. 

Strychnine poisoning often closely resembles tetanus, but there is 
no beginning trismus and more rapid development of the symptoms. 
No history. 

Hydrophobia does not have trismus, but respiratory spasm, excited 
by attempts at swallowing,- with increasing mental symptoms. 

Prognosis. Unfavorable. The great majority die. 

Treatment. Rest and quiet in a dark room. Chloral, potassii 
bromidum, cJiloralamid, morphincz sulphas, and paraldehyde are each 
useful in cases, to hold in check or lessen the severity of the spasm 
for a time. Inhalations of chloroformum will control the spasms, and 
recoveries have been attributed to its use. Physostigma and anii- 
pyrin are recommended to remove the spasms. 

Success has been reported in a number of cases from full doses, 
very early in the attack, of the tetanus serum. 

Success is reported from acidum carbolicum, gr. iij (0.2 Gm.) a day, 
rapidly increasing until gr. vj-viij (o 4-0.5 Gm.) per day is reached, 
by the hypodermic method, a tolerance to the drug being noted in 
tetanus. Baccelli's method of using acidum carbolicum consists in the 
administration, hypodermically, of a two per cent, solution of the 



500 PRACTICE OF MEDICINE. 

acid at two or three hours' intervals. Other methods are to be con- 
tinued in addition to the acid. 

The nutrition must be maintained ; often, on account of the stiff- 
ness of the masseters, rectal alimentation must be resorted to. 



OCCUPATION NEUROSES. 

Synonyms. Professional neuroses ; artisans' cramp. 

Varieties. Writers' cramp ; piano-players' cramp ; telegraphists' 
cramp ; violin-players' cramp ; dancers' cramp. 

Definition. A group of affections of the nervous system, charac- 
terized by the occurrence of spasm (cramp) and pain in groups of 
muscles, in consequence of overuse or frequently-repeated muscular 
acts. 

Cause. Undetermined. It has been noticed that many persons 
suffering from occupation neuroses have a family history of nervous 
affections. 

Symptoms. The symptoms of any of the varieties named gener- 
ally develop gradually and slowly, by a feeling of stiffness in the used 
member, the part feels fatigued and heavy, until it is impossible to 
use it, from the occurrence of spasmodic contractions. Pain on using 
the affected muscles, often associated with tremor, and in many cases 
with an actual paralysis. 

Associated with the loss of power to follow the usual occupation is 
nervousness, 7nental worry , and often depression. There is often the 
sensation of prickling and numbness in the crippled member. 

The electro-contractility is preserved until the atrophy of non-use 
develops. 

Diagnosis. Calling to mind the history of the case and its re- 
sults, in being limited to one member, the nature of the condition is 
evident. 

Prognosis. Often unfavorable. Some recoveries are reported. 

Treatment. Rest of the part and mental quiet, with tonics and 
other means to improve the general nutrition. Faradism in weak 
doses once or twice weekly seems useful. The following combina- 
tion was of value in one case of writers' cramp and in a most 
aggravated case of ballet-dancers' cramp, each affecting the left 
limb : 



n 

s 



GENERAL OR NUTRITIONAL DISEASES. 501 

R . Zinci phosphidi, gr. Ij .13 Gm. 

Ext. nucis vomicae, gr. x .6 Gm. 

Ferri albuminat. , gr. xxx 2. Gm. 

Ft. pil. No. xxx. 
Sig. — One after meals. 



PARALYSIS AGITANS. 

Synonyms. Shaking palsy ; Parkinson's disease. 

Definition. A nervous disease of unknown pathology, charac- 
terized by tremors, progressive loss of power in the affected muscles, 
moderate rigidity, with alterations in the gait, and at times mental 
changes. 

Cause. Age seems to be an etiological factor, most cases devel- 
oping after fifty years. Most frequent in women. 

Pathological Anatomy. No characteristic lesion yet deter- 
mined. It being a disease of past middle life, there is probably an 
interstitial hyperplasia of some layer of the cortex, from alterations in 
the intima of the vessels. 

Symptoms. The onset is gradual, the tremor beginning in one 
of the extremities, oftenest the hand and forearm. At first it can 
be controlled by the will, for a time at least, and is suspended by 
voluntary movement. The disease gradually extends until an entire 
side or the upper or lower limbs are involved. The face and head 
rarely present tremors, but are not exempt. A peculiar rigidity of 
the affected muscles is characteristic of the advanced stage. "At this 
stage of the disease the hands are apt to assume the so-called bread- 
crumbling position, i. e., the thumb and the fingers approximate and 
move restlessly over one another, as in the act of crumbling bread. 
There is often a tendency on the patient's part to go forward, — so- 
alled propulsion, — and this is sometimes so marked that if the patient 
s once started in a walk forward, his gait becomes more and more 
rapid, and he cannot stop himself" (Gray). The patients are usually 
restless and annoyed with insomnia. The general health is fair. The 
mind is generally retained, although melancholia and mild dementia 
have been noted in a few cases. 

Diagnosis. Disseminated sclerosis has a tremor, but only on vol- 
untary movements — intention tremor. There is also scanning speech 
and ataxic gait, with mental enfeeblement, as shown by an unnatural 
contentment with the physical condition and surroundings. 



502 PRACTICE OF MEDICINE. 

Chorea is a tremor, but the movements are general, and particu- 
larly involving the muscles of the face. Again, chorea is a disease 
of children and young adults. 

Prognosis. Radical cure not seen. Improvement often results 
from early treatment. The disease does not tend to shorten life. 

Treatment. The patient should be placed at rest, bodily and 
mentally. Nutritious food, oleum morrhuce, hypophosphites, and ar- 
se nicum. 

Hyoscyamince sulphas, gr. ^"tu (0.002-0.006 Gm.) three times 
daily, is a valuable remedy. Good results have followed the use of 
hyoscince hydrobromas, gr. ^^ (0.00032-0.00065 Gm.) three times 
daily. Mild ga Ivan is ?n, twice or three times a week, acts as a ner- 
vous stimulant. 

MYXCEDEMA. 

Definition. A progressive disease characterized by an infiltra- 
tion of the connective tissue with a gelatinous substance, general 
failure of the health and mental failure, due to or associated with 
atrophy of the thyroid gland. 

Cretinism is considered very akin to myxcedema, save that it is a 
congenital condition associated with alteration or absence of the 
thyroid gland. 

Cachexia strumipriva, a condition following the extirpation of the 
thyroid gland, especially in the young, gives symptoms resembling 
myxcedema. 

Causes. The cause of the atrophy of the thyroid gland is un- 
known. More frequent in women than in men. Usually develops 
about middle life. The disease is said to have followed the extirpa- 
tion of the gland in the adult. 

Morbid Anatomy. Atrophy of the thyroid gland, sometimes 
more advanced in one lobe than the other. " The pituitary body has 
been found increased in size " (Wood). Until the functions of the 
thyroid gland are more fully understood, the steps in the changes re- 
sulting from its atrophy can not be explained. 

Symptoms. The disease develops slowly, often a number of 
years elapsing before all the characteristic phenomena are present. 
The face and neck, and often other parts of the body, have a bloated 
appearance. The normal wrinkles are obliterated, the nose is wide 



GENERAL OR NUTRITIONAL DISEASES. 503 

and thick, the lips thick and everted, the mouth enlarged, as is the 
tongue, giving a coarse and broadened or mask like appearance to 
the features. The skin is denser and does not pit on pressure, but is 
pale or chalk-like, or yellowish-white, with often a small reddish 
patch on either cheek. The expression of the countenance is immo- 
bile and stupid. 

The hands and feet are enlarged, the skin is coarse and dry. The 
shape of the hands is changed, presenting a "spade-like" appear- 
ance. 

The mental condition is sluggish and stupid, with loss of memory 
and of interest in the environments and affairs of life. Occasionally 
hallucinations of sight occur. The tendency is toward a dementia. 
Patients often complain of neuralgic pains and numbness and a 
sense of muscular weakness. The temperature is always below the 
normal. Anaemia develops, and often a subacute nephritis or a gly- 
cosuria or a terminal phthisis. 

Diagnosis. Dropsy or a general oedema has a superficial like- 
ness to myxcedema, but a study of the symptoms should prevent 
error, as pitting on pressure does not occur in myxcedema. 

Prognosis. Under treatment a great improvement can be had, 
but whether a permanent cure results is not yet fully determined. 

Treatment. Protect the surface by warm clothing. Warm bath- 
ing, followed by inunctions of olive oil, and a nutritious, easily 
assimilated diet. 

For the disease, wonderful results have followed from the persistent 
use of thyroid extract. The dose must be carefully watched. Begin- 
ning with gr. y z (0.03 Gm.) after meals, gradually increasing the amount 
untilseveral grains a day are administered, and continued for a long 
time, unless symptoms of thyroidism occur, when the remedy must be 
discontinued for a time. The evidences of thyroidism are shown by 
great nervousness and restlessness, with shortness of breath, which 
becomes embarrassed upon exertion ; rapid pulse with palpitation ; 
confusion of mind, or even delirium, and insomnia and gastrointes- 
tinal disorders. 

For the anaemia and muscular weakness good results follow the use 
of strychnines arseniatis, gr. ■£$ (0.00 1 Gm.), combined with ferritin. 
Nuclein might be added to the treatment with advantage. 



504 PRACTICE OF MEDICINE. 



MENTAL DISEASES. 



MELANCHOLIA. 

Synonyms. Depression of spirits ; psychalgia. 

Definition. A variety of mental alienation, characterized by more 
or less profound depression of the emotions, with either no marked 
intellectual disturbance or the presence of more or less incoherence, 
and the association of hallucinations and delusions. The cerebral 
mechanism developing a condition of supersensitiveness, all impres- 
sions being exaggerated, and a state of abnormal self-consciousness 
existing. 

Varieties. Melancholia simplex ; melancholia hallucinatory ; 
melancholia agitata ; melancholia attonita ; melancholia hypochon- 
driacal ; chronic melancholia ; senile melancholia. 

Causes. Hereditary predisposition. Failing health. Grief. Do- 
mestic and financial worries. Neurasthenia. Menstrual irregularities, 
pregnancy, childbirth, or lactation. Climacteric. Gastric and intes- 
tinal irregularities. Alcoholic and sexual excesses. Organic brain 
diseases. Religion rarely causes insanity, though it frequently gives 
color to it. Most frequent in women and in the young. Attacks of 
melancholia are more frequent in the spring and early summer 
months, and statistics also show that suicides are more frequent 
during this period. 

Pathology. The alterations in the nerve structure, underlying 
an attack of melancholia, are undetermined. Anaemia and sluggish 
nervous energy are constant phenomena, but are hardly the only 
conditions disturbing the cortex. 

Symptoms. Melancholia may be the initial stage of a mania, 
delusional insanity, or paretic dementia, or a stage oifolie circulaire. 

Mental : The cardinal condition is a feeling of depression, misery, or 
mental anguish or pain, for which no adequate cause may exist. The 
onset is usually gradual, with a disposition to neglect duties and self, 
the patient worrying over a something he cannot explain. The 
world is dark and gloomy, with a foreboding of some awful calamity 






MENTAL DISEASES. 505 

that is to affect or wreck the patient or his family. Suspicion, dis- 
trust, and, often, fear of wife, children, relatives, or friends. Insom- 
nia is a constant and stubborn symptom. The memory is maintained, 
and the reasoning faculties are usually intact, except upon the painful 
sensations. The patient may sit quietly, declining or unable to talk 
(silent melancholia, or mutism), or be restless, according to the char- 
acter of the emotions affected. 

Physical : The patient presents either an anxious or a woe-begone 
expression. Headache, and particularly a post-cervical ache, is a 
very constant symptom. The skin is dry and harsh, the respirations 
superficial, the cardiac action slow and feeble ; there is gastric catarrh, 
constipation, and scanty, high-colored urine. The tongue is flabby 
and coated, and the appetite is poor. The refusal to take food is most 
characteristic. 

Hallucinatory melancholia is an aggravated form of the disease, 
where, in addition to the painful mental reflexes, are distressing hal- 
lucinations and illusions, the patient living in a realm of terror. The 
attack may be the result of a delusion, but much more frequently the 
depression and foreboding give rise to the delusion. The delusions 
of melancholia are usually of self-accusation, self-abasement, and 
justified persecution ; the patient feels that he is being punished for 
some transgression, imaginary or otherwise. 

The manias of persecution and the monomanias of suspicion are 
all of a melancholic type, the result of painful hallucinations. 

Hypochondriacal melancholia shows all subjective impressions with 
disturbed memory, leading to the belief that the bowels have been 
removed, food cannot be digested, that the brain has turned around, 
that the blood cannot circulate, and that gallons of blood have been 
drawn from the body. These distressed individuals are often con- 
scious of every organ of the body and experience disagreeable impres- 
sions coming from them all, and as a consequence are irritable, fretful, 
and exacting. It is to be remembered that not uncommonly these 
patients really have an organic disease giving a foundation for the 
delusions. 

Melancholia agitata are those sad cases in continual agitation, in 
which the fearful and distressful thoughts and imaginations cause 
wringing of the hands, restless walking, rhythmic swaying of the body, 
and prayers beseeching help, with tears flowing down their cheeks, 
crying out for assistance and protection. Incoherence and violent 
43 



506 PRACTICE OF MEDICINE. 

impulses are frequent, the excitement often resembling an attack of 
mania. 

Melancholia attonita, or melancholia with stupor, the patients 
seeming to be overwhelmed, sitting mute, motionless, and expres- 
sionless, refusing to assist themselves in any way, and often requiring 
mechanical feeding. Memory is usually impaired in this variety ; 
and attacks of violence may occur. 

Chronic melancholia is the continuation of the depression over a 
long period, the individual living in the fear of impending danger or 
punishment for supposed acts for long periods of time, often with 
apparent lucid periods. 

Senile melancholia is a condition of extreme mental distress associ- 
ated with beginning senile dementia. 

Suicidal impulses are present in a fair proportion of cases of mel- 
ancholia, and unless there be everlasting vigilance the patient will 
succeed in his insane desire. 

Diagnosis. The cases of simple melancholia are readily deter- 
mined. Melancholia agitata is frequently mistaken for acute mania. 
Melancholia attonita closely resembles acute dementia — a condition, 
it is but fair to mention, denied by many alienists. 

Prognosis. A typical attack of melancholia runs a definite 
course, not unlike the typical course of a fever. Favorable in the 
mild cases of all forms not associated with organic disease, and who 
have not reached the climacteric. Delusional melancholia has the 
most unfavorable prognosis. Pronounced cases of melancholia 
attonita are more apt to terminate in dementia than any other variety. 

Treatment. Change of environment and rest are essential. 
Attention to the gastro-intestinal canal is of the greatest importance, 
as the dyspepsia and constipation of melancholic patients is a 
barrier to their recovery. Frequent bathing, with friction to the sur- 
face, aids in the eliminative action of the skin. The diet must be 
of the most nutritious character. If food be persistently refused, 
mechanical feeding must be practiced. The late Dr. Gray was a 
strong advocate of small doses of opium, or morphina, in acute 
melancholia, and in properly selected cases it is a most valuable 
agent. Tincticrce quebracho, 3j-ij (4-8 Gm.), well diluted, three times 
daily, is often a valuable remedy. If the arterial tension is relaxed, 
good results follow the use of digitalis. Sodii phosphas is often useful. 

Many cases of melancholia seem to be due to a brain fatigue, and 



MENTAL DISEASES. 507 

if the patient can be given many hours' sleep in the early days of 
the attack recovery is assured. 

I have seen excellent results in melancholia attonita from cannabis 
indices in increasing doses. 

Such tonics as quinines sulphas, arsenicum , ferritin , and strychnines 
sulphas or arseniatis are all of value in building up the patient. As 
the strength improves, open-air exercise must be added to the other 
means used. 

Insomnia must be combated by evening bathing and feeding, and 
the use of chloral, trional, sulphonal, or hyoscina at bed-time. 



MANIA. 

Synonyms. Insanity ; madness. 

Definition. An intense mental exaltation, with great excitement, 
loss of self-control, with, at times, absolute incoherence of speech, 
and loss of consciousness and memory. (Clouston.) 

Mania is a condition characterized by an abnormal exaltation and 
activity of the mental functions, — the intellectual faculties, the emo- 
tions, and the will, — and may show itself by irrational talking and 
acting, by delusions, illusions, and hallucinations, and by unusual 
muscular activity or movements. (Chapin.) 

A mental condition in which there is an emotional exaltation, ac- 
companied by illusions, hallucinations, delusions, great mental and 
physical excitement, and a complete loss of the inhibitory power of 
the will ; in acute cases, and frequently in chronic forms of the dis- 
ease, there is a marked destructiveness and a tendency to violence. 
(Wood.) 

An attack of mania may be acute, subacute, or chronic. 

Causes. Inflammation or other organic disease of the brain or 
its membranes. Mental shock or strain. Worry — domestic, moral, 
or financial. Excesses in alcohol, venery, or tobacco. Ovarian dis- 
ease, or menstrual irregularities. Climacteric in those of nervous 
disposition. Pregnancy, parturition, or lactation. Nephritis. Anae- 
mia. Syphilis. Hereditary predisposition. 

Pathology. There are no constant morbid changes associated 
with mania. In all varieties of acute insanity there exists vitiated 
nervous energy or impaired vitality, the result of overexcitement or 



508 PRACTICE OF MEDICINE. 

overstimulation, motor disturbance, or auto-infection, the result of 
the imperfect elimination of the products of tissue waste. " There is 
no reason why a mere dynamical brain disturbance should not kill 
and leave no structural trace, any more than that it should for months 
abolish judgment, affection, and memory, and then pass off and leave 
the brain and all its functions intact/' (Clouston.) 

If death follow the acute symptoms, the vessels of the brain and 
membranes are engorged, but in the majority of instances the brain 
structure is normal. 

If death occur in chronic mania, the most frequent change found 
will be a thickened and adherent dura mater. As observed, any form 
of organic change may be found post-mortern in those dying of any 
form of mania. 

Symptoms. Acute Mania : The onset may be abrupt, or fol- 
lowing a period of emotional depression, associated with lassitude, 
feeling of unrest, disinclination to work, and disorders of the gastro- 
intestinal canal, with insomnia and an introspection ; these symptoms 
are termed the melancholic stage of mania. 

The inaniacal stage is characterized by loud talking, intense ego- 
tism, violent motions of the limbs and body, great restlessness, and 
excitement ; the thoughts flow with wonderful freedom and amazing 
rapidity, the condition often resembling the symptoms of early alco- 
holic intoxication ; as the exaltation continues the patient becomes 
either sullen, irritable, and angry, offering violence to those around 
him, or he becomes garrulous, talking of his personal affairs, is 
confidential and communicative to .strangers, often making egotistic 
offers, passing frequently into incoherence of language and action. 
Sexual passions are frequently exalted, and acts of masturbation 
practiced, with outbreaks of vulgar, obscene, and profane language, 
which is entirely foreign to the individual in mental health. Delu- 
sions are an almost constant symptom, of a superficial or transitory 
character, changing with every new appearing mood. The maniacal 
patient is sleepless, or may have short naps, at once continuing his 
chatter on awakening. 

Any attack may show all of the symptoms mentioned, or any one 
or more of them, but the great majority of cases show intense egotism , 
loud talking, violent motion of limbs or body, hurry, exciteme?it, in- 
somnia, incoherence, and incessant noise. 

The course of an attack shows periods of remissions and exacerba- 



MENTAL DISEASES. 509 

tions, with nocturnal crises ; loss of flesh and mental weakness are 
often marked as the attack progresses. 

Acute delirious mania, typhomania, is a psychosis of sudden onset, 
attended with increased bodily temperature, dry tongue, quick, feeble 
pulse, scanty urine, and marked by delirium with sensuous hallucina- 
tions, marked incoherence, restlessness, refusal of food, loss of 
memory, and rapid bodily wasting, terminating frequently in death. 

Amenorrhceal mania are attacks of mania occurring at the men- 
strual epoch. Homicidal, suicidal, and various hysterical impulses 
are frequent. 

Mania-a-potu is an attack of acute delirium, due to alcoholic ex- 
cesses in those engaged in a sudden debauch, or who have drunk 
heavily and eaten little, for a comparatively short period. 

Asthenic maiiia, in which there is general anaemia associated with 
neurasthenic symptoms. 

Dancing mania is a hysterical mental state in which, through sym- 
pathy and imitation, dancing of a most grotesque and extravagant 
character occurs. Usually epidemic. 

Delusional mania is the result of fixed delusions, either causing or 
associated with the maniacal outbreak. 

Erotic mania, erotomania, presents systematized delusions of an 
erotic character, not necessarily accompanied by animal sexual desire. 
Nymphomania is a morbid, irresistible impulse to satisfy the sexual 
appetite, and is peculiar to the female sex. 

Epileptic mania follows an epileptic paroxysm, and is often of a 
most violent kind, the maniacal acts being of the most treacherous 
and malicious character. 

Hallucinatory mania presents visual, auditory, olfactory, and other 
sense hallucinations. 

Homicidal mania is any variety of mental disease in which there is 
a desire or an attempt on the part of the patient to commit murder. 
The condition may be the result of delusions that the persons attacked 
either are persecuting or going to kill the patient, or of the excessive 
excitement that vents itself in destructiveness, combativeness, or 
desire to kill, or there may be a morbid desire, impulse, or craving to 
do murder, or the homicidal act may be unconsciously done during 
an acute delirium, or a paretic or epileptic maniacal impulse. In 
cases of murder the question of responsibility or the difference between 
the insane criminal and the criminal is not always readily determined. 



510 PRACTICE OF MEDICINE. 

With insane criminals, in the act itself lies the satisfaction and 
not the object, while with criminals the act is only a means to an end ; 
to the former crime is a pleasure, to the latter a paying business, 
necessitating, it may be, disagreeable or horrible acts. 

Morphinomania is the insane craving for the stimulating action of 
morphia — a moral insanity. 

Puerperal 7iia7iia is the maniacal outbreak as seen in the puerperal 
woman, This is now thought to be of septic origin, although the 
mental strain through which the female has been passing is a predis- 
posing factor in those who have a neurotic history. 

Transitory ma?iia, or ephemeral mania, is a rare form of maniacal 
excitement of sudden onset, violent and decided in character, accom- 
panied by great insomnia, incoherence, and more or less complete 
unconsciousness of familiar surroundings. The attack as suddenly 
terminates, the duration being from a few hours to a few days. 

Senile mania is the mental exaltation occurring in persons with 
senile arterial changes or senile cerebral atrophy. Soon followed by 
dementia. 

Recurrent mania, or chronic mania with lucid intervals of longer or 
shorter duration. Generally of alcoholic origin. 

A maniacal outbreak may present any one or a number of the 
varieties named. 

Chronic Mania : A condition of continual mental exaltation, the 
acute symptoms having continued in a chronic course. The line that 
distinguishes between an acute and chronic mania must always be 
somewhat arbitrary and unscientific. The duration of the mania 
beyond twelve months is usually considered sufficient to determine 
the condition, and this is well, as it precludes the possibility of term- 
ing the condition incurable. If the term chronic mania was restricted 
to those cases in which, between the exacerbations of restlessness, 
excitement, and destructiveness, were evidences of dementia, less 
confusion would occur. 

Terminations of Mania. About fifty per centum of acute 
manias, not due to organic disease, recover after periods varying from 
one month to several years. A fair proportion of cases make a partial 
recovery and are able to return to their work, but always showing 
some alteration in character or affection, or some eccentricity, or a 
slight mental weakness. About twenty per centum of cases terminate 
in dementia or mental death, and this is alwavs the fear in each case. 



MENTAL DISEASES. 511 

Two per centum of cases die, either the result of exhaustion or from 
the organic condition causing or associated with the attack. 

Prognosis. The question of recovery, partial or complete, is 
always difficult to determine, depending upon the cause, temperament, 
disposition, education, nationality, and the normal mentality of the 
individual. Recovery is usually gradual ; rarely sudden restoration 
occurs. 

Favorable indications are : sudden onset, short duration, youth of 
patient, absence of fixed delusions, good appetite, increasing hours 
of sleep ; moderate or no increase in temperature, pulse, and respira- 
tion ; no evidences of mental weakness, no paralysis or alteration of 
pupils or articulation, no epilepsy, no unconsciousness to the calls of 
nature, and no former attacks. Unfavorable indications are the 
opposite of these, and also the presence of organic brain disease, or 
a strong hereditary tendency, or the possession of an excitable dispo- 
sition or nervous diathesis. 

Treatment. The indications for treatment are to quiet the exalted 
mentality and to promote constructive metamorphosis. Every means 
should be used to lessen the excitement of the patient and produce 
refreshing sleep. A hot or warm bath is frequently one of the most 
soothing means of reducing excitement; changing the environment 
of the patient and placing him under the care of a good, firm, but 
kind and intelligent nurse is of importance ; the society or visits of 
the family or friends must be forbidden, for visits act as stimulants to 
the disordered intellect and encourage discussion on the part of the 
patient as to the character of the treatment, and thus reduce the dis- 
cipline so essential to early recovery. 

If means of this character are unavailing, and, unfortunately, in the 
majority of attacks they will be, then resort must be had to sedatives, 
for every day's continuance of the maniacal outbreaks lessens the 
chances of restoration. Amongst the drugs having a distinct value 
are hyoscince hydrobromas, gr. ^thj - cV (0-00032-0.001 Gm.), repeated 
two or three times daily, watching its effect on the pupils ; sulphonal, 
gr. xx (1.3 Gm.), repeated with caution, watching its effect upon the 
heart and respiration ; chloralamidum, gr. xxx-xl (2-2.6 Gm.), repeated 
three or four times daily ;' or, irional, gr. xxx (2 Gm.), repeated in two 
or four hours ; this latter is one of the most reliable drugs for maniacal 
excitement and insomnia we now possess. I have seen excellent 
results from the use of passiflora incarnata, either as a tinctura, in 



512 PRACTICE OF MEDICINE. 

f3j-*3»ij (4-8 Cc.) doses, several times daily, or as extractum fluidum 
in smaller doses. Patients with much excitement and a weak pulse 
are benefited with full doses of the bromides and digitalis. If the 
muscular excitement is pronounced, good results follow morphines 
sulphas, hypodermically ; it may be combined with either atropi?i(2 
sulphas, hyoscincB hydrobro?nas, or duboisincs sulphas. 

In attacks of acute mania, with flushed face, throbbing arteries, 
full pulse, and delirious excitement, excellent results follow the 
use of extractum gelsemii fluidum, tf\,ij (0.12 Cc), every hour, until dila- 
tation of the pupils and ptosis develop, unless improvement sooner 
occur; tinctures veratri viridis,V(\Jij-v (0.12-0.3 Cc), is also useful. 
Post-epileptic excitement is best controlled with large doses of chloral, 
by the mouth or rectum. Ice or cold to the head is useful in cases 
with flushed face and throbbing temporals. 

The general condition of the patient calls for the most prompt and 
efficient treatment. Attention to the gastro-intestinal canal and kid- 
neys is of paramount importance, as many attacks of mania are the 
result of auto-intoxication from the retention of the products of mal- 
assimilation and tissue waste. The diet should be of the most nutri- 
tious character, administered at frequent intervals — peptonized or hot 
milk, hot broths, eggs, and often alcoholic or malt liquors. 

Patients not infrequently refuse food on account of lack of appe- 
tite, abhorrence for food, or from fear of poisoning, when recourse 
must be had to the naso-stomachic tube, or nutritive enemata. If the 
breath be heavy, the tongue badly coated, the bowels costive, and 
the skin sallow, the very best results follow washing out the stomach, 
provided the maniacal condition permits. 

Tonics are of great value, a combination like the following always 
being beneficial :' 

1 \ . Quinine sulphat., gr. xlviij 3.1 Gm. 

Strychnine sulphat., gr. ss .032 Gm. 

Acid, hydrochlor. dil., f.^i'j I2 - Cc. 

Aqu;e chloroformi, f % iij 90. Cc. 

Aquae menthae pip., . . q. s. ad f,$vj ad 180. Cc. M. 

SiG. — Dessertspoonful, diluted, every four or six hours. 

The question of removal to a hospital for the insane arises in nearly 
all cases, and should in my judgment be answered, in the vast ma- 
jority of instances, in the affirmative, as the discipline, regular hours, 
and order of a well-managed hospit.il for the insane have a most 
remarkable effect on the majority of insane patients. 



MENTAL DISEASES. 513 



EPILEPTIC INSANITY. 



Definition. A mental condition caused by or the result of epi- 
lepsy. 

Causes. The careful study of the brain of those dying having 
epileptic insanity has failed to determine why some epileptics suffer 
from any of the insanities and others have their normal mentality, 
and another group are better after a convulsion. 

I am familiar with ten cases of epilepsy who all seem much brighter, 
mentally, after their paroxysm, but in whom, after a drinking bout, 
each epileptic attack is followed by a wicked homicidal mania of 
many weeks' duration. 

Varieties. Pre-epileptic mania ; post-epileptic mania ; dementia 
epileptica ; imbecility with epilepsy. 

Symptoms. The mental changes constituting epileptic insanity, 
save in the cases of epilepsy with imbecility or idiocy, develop after 
some years of the ordinary epileptic paroxysms. 

Pre-epileptic mania has attacks of mania some days or hours pre- 
ceding the epileptic convulsion. The patient is morose, irritable, and 
threatening, often making homicidal attacks on those around him, be 
they friends or foes. Rarely the epileptic seizure is replaced by various 
insane or so-called hysterical acts, as fits of dancing, laughing, crying, 
screaming, swearing, or scolding. 

Post-epileptic mania follows the epileptic paroxysm, either taking 
the place of the comatose state or following it. The maniacal acts 
during these outbreaks are often of the most desperate and im- 
pulsive character, many an asylum physician and attendant carrying 
scars the result of attacks of post-epileptic maniacs. 

Epileptic dementia is the terminal mental obliquity resulting in 
about thirty per centum of insane epileptics who do not succumb 
before to nephritis or tuberculosis. 

Epileptic imbecility is a congenital condition in which epilepsy and 
imbecility are associated. 

Prognosis. The great majority of persons suffering from epileptic 
insanity develop, sooner or later, either nephritis or tuberculosis. 

Recovery from epileptic mania is a rare occurrence, although I 
am familiar with two cases. Thirty per centum of epileptic maniacs 
progress to dementia in from five to ten years. 
44 



514 PRACTICE OF MEDICINE. 

Treatment. There is no doubt but that full doses of the bromides 
lessen the severity and frequency of the paroxysms. If the attack 
can be anticipated, it may sometimes be averted by an enema of 
chloral, gr. xx-xxx (1.3-2 Gm.), or chloralamidum, gr. xl-lx (2.6-4 
Gra.), or amyl nitris, vr^v (0.3 Cc), by inhalation or by stomach. For 
the condition of status epilepticus the following combination, alternated 
with saline purgatives, has given good results : 

R. Chloral, gr. xx 1.3 Gm. 

Tinct. cannab. indicse, ^xv I. Cc. 

Inf. digitalis, f^j 30. Cc. M. 

SlG. — Administer as enemata every three or four hours. 

The use of opium for a long period has broken up the recurrent 
maniacal attacks in several patients under my care. 

The general condition of the patient must receive careful attention, 
as there is a strong tendency to the development of nephritis, tuber- 
culosis, and gastric catarrh. This class of patients are great feeders — 
often gluttons — and are sure to eat more than they can properly as- 
similate. Free action of the bowels and kidneys must be promoted. 

Never contradict, nor attempt to reason with, an epileptic during 
the period of excitement. 

CIRCULAR INSANITY. 

Synonym. Folie circulaire. 

Definition. A mental disease characterized by regularly alternat- 
ing and recurring periods of mental exaltation, depression, and semi- 
lucidity. 

Causes. Hereditary predisposition. The exciting causes are 
any of those conditions which depress the brain or general system. 

Pathology. There is no characteristic lesion associated with cir- 
cular insanity. 

Symptoms. Essentially a chronic condition and probably incur- 
able. The disease usually begins as a melancholia, the depression 
being an apathy and torpor rather than a mental pain, and suicidal 
feelings and impulses are rare. This condition is soon succeeded by 
mania, a mental exaltation with hyperaesthesia and exaggeration of 
nervous functions, the reasoning power well retained ; this is in turn 
followed by a semi-lucid interval, often giving promise of recovery, 
to be sooner or later followed by another cycle. These periods fol- 



MENTAL DISEASES. 515 

low each other with remarkable regularity, each being of the same 
duration. Rarely the various periods are of irregular duration. 

The general health is well maintained, the patient gaining in flesh 
during the stages of depression and lucidity and losing during the 
period of exaltation. 

Diagnosis. The regularity of the different periods soon estab- 
lishes the diagnosis. 

Prognosis. Incurable. Ending in dementia after a lapse of 
several years. 

Treatment. Attention to the general health and meeting the 
symptoms of the different periods as they recur. No means known 
to prevent the recurrence of the periods. 



KATATONIA. 

Synonyms. Alternating insanity ; Kahlbaum's insanity. 

Definition. A mental disease characterized by irregular cyclical 
symptoms, ranging from melancholia to mania, followed by stupidity 
and confusion, with cataleptoid phenomena, followed by lucidity for 
a time, recovery, or passing to a dementia. 

Causes. Hereditary predisposition. The exciting causes are usu- 
ally the result of some excess. Rarely associated with organic brain 
disease. 

Pathology. No characteristic lesions have been found associated 
with katatonia. 

Symptoms. A typical case begins as a 7Jielancholia, the mental 
depression, uneasiness, and distress followed after a variable period 
by mania, associated with hallucinations and delusions. This period is 
followed in turn by a condition of attonita, or rigidity and immobility, 
or a cataleptoid paroxysm. Any of the stages may be followed by 
confusional symptoms, or a true dementia may develop. During the 
maniacal stage there is a tendency, in many cases, to histrionic and 
sermon-like declamation, or the speech may be of the verbigeration 
character — that noisy, incoherent, and meaningless speech seen in 
many manias, composed largely of the constant repetition of a few 
words or phrases without sense or sequence (onomatomania). 

During the stage of attonita the presence of the so-called mutism 
or mutaeismus, " a pathological tendency to be silent," may continue 



516 PRACTICE OF MEDICINE. 

for days, weeks, or months, or it may be interrupted by periods of 
verbigeration. 

The immobility or rigidity so characteristic of a period of katatonia 
is frequently alternated with automatic, incessant, and monotonous 
movements — the stereotyped movements. 

Patients suffering from katatonia often refuse food for days at a 
time and then suddenly present symptoms of boulimia. Vasomotor 
and trophic changes are frequent, one of the most constant being 
cyanosis of the hands and other peripheral parts. Hsematoma auris, 
insane ear, or perichondritis auriculae, is frequent. Epileptiform 
attacks may usher in the disease or occur during any of its stages. 

Diagnosis. It may be diagnosed as melancholia, mania, or a 
dementia, depending upon which of the cycles be first observed, 
but after being under observation long enough to note a complete 
cycle the diagnosis is readily determined. Katatonia differs from 
circular insanity in the presence of the stage of attonita and catalepsy. 

Prognosis. The disease may continue for a number of years 
and recovery follow, but as a rule the prognosis is unfavorable. 

Treatment. Attention to the general condition, and combating 
the various symptoms as they arise. In cases associated with anaemia, 
arse7iicum and strychnina seem to be valuable, Two cases were 
rapidly improved with small doses of hyoscince hydrobromas, gr. 
■ZTjjj-zhs (0.00022-0.00032 Gm.) morning and evening. When food is 
refused by the insane, and stomachic or nasal tube or rectal feeding 
is necessary, the stage of food refusal is often wonderfully shortened 
by adding sulphonal, gr. x-xv (0.6-1 Gm.), to each feeding. 



DELUSIONAL INSANITY. 

Synonyms. Delusional mania ; delusional melancholia ; primary 
delusional insanity. 

Definition. A mental state, with fixed or partly systematized 
delusions, associated with either brain exaltation or excitement with- 
out maniacal acts, or a mental depression, minus the somatic symp- 
toms of melancholia. 

An- insane delusion is a false belief for which there is or may be no 
reasonable foundation and which would be incredible under the given 
circumstances to the same person if of sound mind, and concerning 



MENTAL DISEASES. 517 

which his mind is not open to permanent correction through evidence 
or argument. 

"An insane delusion. is a belief in something that would be in- 
credible to sane people of the same class, education, or race as the 
person who expresses it, this resulting from diseased working of the 
brain convolutions." 

Causes. Cerebral and bodily exhaustion the result of overwork, 
neglect of personal hygiene, or alcoholic, tobacco, drug, or sexual 
excesses — a neurasthenia. Impairment of the nervous centers, the 
result of fevers or shock. Climacteric period, worry, and insufficient 
food. 

Pathology. Delusional insanity is a subacute or chronic condi- 
tion ; death seldom occurring, and when it does is the result of an 
intercurrent physical malady. In the few such cases in which post- 
mortem examinations have been made, the vessels of the brain were 
found torpid or dilated — a vasomotor paresis causing an imperfect 
cerebral circulation. 

Symptoms. Either following an attack of acute mania or melan- 
cholia, but more commonly without either of these conditions, occurs 
a set dehtsion or delusions, which, to the patient, are so real that no 
amount of argument can dispel his or her belief. These cases are often 
classed as manias or melancholias, but, as they do not run the ordi- 
nary course of either of these conditions, they are best classed clinic- 
ally by themselves. The acuteness or subacuteness of the attack distin- 
guishes them from paranoia. Among the almost endless variety of 
delusions mention will be made of a few that have come under recent 
notice : A young man of twenty believes that he is President Cleve- 
land ; another patient, a driver, believed for ten months that he was 
the owner of a thousand horses, any one of which was worth thousands 
of dollars ; he made a perfect recovery and now laughs at his old 
delusions. A young man of twenty-five believes his mother is not 
his mother, but the woman he boarded with, and that his brothers and 
sisters are her children but no relation to him. A young woman of 
thirty believes she is pregnant by a prominent merchant ; the fact 
being she is not and never has been pregnant. The majority of the 
delusions are of an egotistical character, but lack the conduct or 
appearance of the position due to the character of the delusion. A 
patient with ragged clothing will assure you that he is worth millions, 
and yet sees nothing inconsistent between his delusion and his 



518 PRACTICE OF MEDICINE. 

personal appearance. Another will assure you of his vast business 
interests, and yet remains contented in the hospital wards, laboring 
faithfully in the kitchen or laundry. A woman assures you that she 
is the great Patti, receiving thousands of dollars for each operatic 
performance, and yet is apparently happy in the sewing-room. 

An hallucination is an imperfect perception through any one of the 
senses. A person who imagines that he sees something, or hears 
something, or tastes something, or feels or smells something that he is 
not seeing, hearing, tasting, feeling, or smelling, has an hallucination. 

Delusional insanity is often based upon the development of hallu- 
cinations of the special senses, that of hearing being the most fre- 
quent ; patients hear " voices " telling them what to do or not to do, 
and a delusion is built up and developed. Again, " voices " upbraid 
them or charge them with various acts, and upon this is developed a 
persecutory delusion that causes them much unrest. The following 
case has lasted for five years, and while the patient is at times 
apprehensive of some evil that may result to her, and uses judg- 
ment to protect herself, yet is not, nor never has been, melan- 
cholic, or shown any evidences, other than her present belief, of 
mental failure. She enjoys fair health, and partakes of the world's 
pleasures. Six years ago her husband suddenly died and the settling 
of a large estate was thrown upon the patient. Sitting in her hotel 
at the window, about five years ago, she saw a man come to the 
window in a building opposite to where she was, and make some 
motion to her. She was greatly alarmed. That evening, while walk- 
ing on one of the busiest streets of the city, she distinctly heard a 
young man, in passing, make an improper proposal to her, and she 
has never walked on that street since without the same thing occur- 
ring, although not always by the same person. Her daughter, who 
accompanied her, did not hear the proposal, nor has she ever heard it, 
although, I regret to say, is gradually becoming convinced it must be 
true. Now for the sequel : the woman is not depressed or worried, 
shows no evidences of melancholia, talks about the affair as if it were 
a fact, which it unfortunately appears to her, and avoids the unpleas- 
antness by never again walking on the particular street nor going in 
that neighborhood. 

Again, visions appear, which result in delusions of personal impor- 
tance. Taste and smell may be perverted, causing prolonged fasting, 
often from fear of poisoning. 



MENTAL DISEASES. 519 

Diagnosis. Delusional mania and delusional melancholia are 
confounded with delusional insanity, the points of distinction being 
the absence of severe maniacal and melancholic acts; the patient 
simply possesses his insane delusion and may never refer to it unless 
questioned. 

Paranoia or monomania and delusional insanity have many symp- 
toms in common, but in the former "their whole thoughts and lives 
show a strong self-consciousness, and their egotism is intense" 
(Chapin) ; and if the patient believes he is Christ, he wishes to be 
so respected, and considers himself wronged if not so treated, while 
the delusional patient will say he is Christ and immediately drop 
the subject. There are, however, many border-land cases in which 
the diagnosis is difficult. 

The distinction made here between paranoia and primary delu- 
sional insanity is not generally accepted. 

Prognosis. In acute primary delusional insanity recovery is fre- 
quent, although the delusions may exist for a number of years. Many 
patients who make a complete recovery will still believe that their 
delusions were facts. A fair proportion of cases pass into the condi- 
tion of chronic delusional insanity, this attack being the first or second 
period of Magnan's classification, viz.: First period, incubation or 
anxiety ; second period, persecution ; third period, grandeur, or 
ambition, or optimism ; fourth period, dementia. 

Treatment. A supporting plan of treatment, with thorough 
action upon the bowels, kidneys, and skin, and plenty of fresh air, is 
of great value in all cases of delusional insanity. If the disease is 
the result of excesses, a course of strychnina and arsenicum is indi- 
cated. A tranquil condition of the brain is essential, and few com- 
binations are so valuable as digitalis and hyoscina, in small, repeated 
doses. Insomnia is an annoying symptom in many cases, and is best 
overcome by a digestible meal at bed-time, or a warm or hot bath in 
the evening, and if these fail a full dose of somnal [R. Somnal, Sfiij 
(12 Cc.) ; glycerini, f^ss (16 Cc); tinct. cardamom, comp., f^ss 
(16 Cc.) ; aquae menthae pip., ad fjiij (90 Cc). M. Sig. — Half-table- 
spoonful, repeated in two hours], well diluted, or trional, gr. xxx 
(2 Gm.), an hour before bed-time, in milk or spirits. 



520 PRACTICE OF MEDICINE. 



PARANOIA. 



Synonyms. Monomania ; chronic delusional insanity : reason- 
ing mania ; Verriicktheit. 

Definition. A chronic mental disease characterized by fixed 
logical or systematized delusions of persecution, unseen or impossible 
agencies, or of self-exaltation, the emotions and memory being only 
paroxysmally defective, while, however, the life of the individual is 
dominated by the delusions. 

The term paranoia is now commonly used to cover a group of 
insanities which are degenerative in origin, chronic in course, and 
characterized by systematized delusions, with little impairment of 
the emotional faculties, and is not generally accepted as a synonym 
for monomania. 

" A primary developmental insanity." " A condition of degener- 
acy." "There is imbecility of mind and there are delusions" 
(Dewey). 

Causes. There is generally a hereditary predisposition to insanity 
in monomania or paranoia. The exciting cause may be the result of 
an acute mania or melancholia, or the result of alcoholism, or the 
result of malnutrition in those who have had a struggle to keep their 
position in the world. Extreme worry in individuals with mental in- 
stability. Following primary or acute delusional insanity. 

Symptoms. The course of monomania is essentially chronic, 
the delusions becoming perfectly fixed and unchanging upon one 
particular subject, or set of subjects, which in turn dominate the life 
of the individual. The most common characters of these systematized 
delusions are delusions of persecution or suspicion, delusions of exal- 
tatio?i or of pride, and delusions of unseen agents or influences. 

A delusio?i of persecution is shown in a woman of average talents 
and education, who has devoted much time, thought, and worry to a 
number of worthless patents, and now that she is in an insane asylum 
believes she has been placed there that others may reap the rewards 
of her inventive genius ; she is constantly annoyed by what the 
physicians, attendants, and patients are doing, claiming that many 
such acts are for the purpose of annoying or harming her, her sus- 
picions being of the most aggravating character. 

Delusion of exaltatio?i or pride is well shown in the case of a man 
who believes he is Jesus Christ, and is angered almost to the point of 






MENTAL DISEASES. 521 

homicide if great consideration is not shown him. Another male, 
whose origin is from the lower walks, believes he is to marry a distin- 
guished authoress, and will resent any doubt of his purpose with blows. 

Delusion of unseen agencies is well shown in the case of a female, 
aged forty years, who labored under the delusion that she was beset 
by numerous devils in her abdomen, the real cause being the presence 
of a cancer of the liver. Patients complain of electrical influences, 
telephonic communications, and invisible agents tormenting them. 

The range the delusions of monomania assume are most wide and 
varied, but always associated with the ego. The patient is being per- 
secuted not because, as in melancholia, ®he has committed some sin, 
or thinks he has, and deserves punishment, but because the perse- 
cutors wish to deprive him of his rights, titles, or estate, or degrade 
him or in some way injure him. 

Diagnosis. In the diagnosis of monomania there are three points 
to ever keep in mind '.first, the duration — the fixed, systematized de- 
lusions must have existed over one year; second, the absence of 
symptoms of mania or melancholia ; and third, the presence of sys- 
tematized delusions affecting the personnel of the individual. 

Prognosis. Monomania is an incurable disease. Unless tuber- 
culosis develop within a few years, dementia results. 

Treatment. Symptomatic, and all means that promote con- 
structive metamorphosis. 



GENERAL PARALYSIS. 

Synonyms. General paresis ; general paralysis of the insane ; 
paresib ; paretic dementia. 

Definition. A subacute or chronic, degenerative disease of the 
brain, sometimes involving the spinal cord; characterized by altera- 
tions in the intellectual and moral character, with the development 
of unsystematized ideas of self-importance or delusions of grandeur, 
finally merging into dementia (preceded by either a mania or a 
melancholia), and the gradual development of tremor, slurring speech, 
pupillary changes, ataxia, trophic changes, and finally paresis. 

Causes. General paralysis of the insane occurs chiefly between 
thirty and fifty-five years of age, and in the male more frequently 
than in the female, although a notable increase in the lower class of 



522 PRACTICE OF MEDICINE. 

females is being observed. It usually affects the robust, middle-aged 
individual, rapidly destroying all intelligence and judgment, leaving 
him to exist, often for months, as a demented human automaton. 

General paresis is increasing, and some one has said its increase is 
in proportion to " syphilization and civilization." 

Predisposing causes: Heredity; an ambitious overstraining for 
prominence, learning, or wealth ; forced intellectual activity in those 
with imperfect or improper early training ; or in those with an imper- 
fectly developed or organized cortex ; cranial injuries ; atheroma. 

Exciting causes : Alcoholic and sexual excesses ; syphilis ; mental 
and physical overstrain ; worry. " In many cases I think the middle- 
aged general paralytic is suffering for the sins of his youth " (Clouston). 

" General paralysis is not a penalty of high cerebral develop- 
ment, but the expression of a discrepancy — an inadequacy of some 
brains to sustain the strain to which the race, as a whole, is sub- 
jected " (Spitzka). 

Pathological Anatomy. A condensed description of the 
pathological basis of general paralysis is difficult. It may be de- 
scribed as a chronic, diffuse, cortical encephalitis. The microscopical 
changes in the cortex, according to Mendel, as quoted by Folsom, are 
as follows : 

1. Increase of nuclei and new cell formation, some nuclei small, 
some large, and with such varying reactions to coloring agents as to 
suggest dissimilarity of origin. The stellate or "spider" cells are 
increased in the upper layer of the cortex, where some may be nor- 
mally found, and extend to lower layers, as is not the case in normal 
brains ; they, too, may be several times the usual size and also push 
through the white substance to the ependyma of the ventricles. Pro- 
liferation of neuroglia or connective tissue, and in time sclerosis of 
the cortex, which involves the medullary substance also in a greater 
or less degree. 

2. The larger blood-vessels may or may not be atheromatous; in 
the capillaries there is an increase of nuclei in the walls, with thicken- 
ing and hyaloid degeneration. 

3. In the nerve-cells, the ganglion-cells, granular and fatty degen- 
eration of protoplasm, sclerosis, atrophy. 

4. Atrophy and final disappearance of the nerve-fibers, not limited 
to the cortex and found in other brain diseases also — senile dementia 
and epilepsy, for instance. 



MENTAL DISEASES. 523 

5. Focal lesions of the most various kinds, and degenerative 
changes in the spinal cord, the several forms of sclerosis and mye- 
litis. 

The spinal cord undergoes atrophy with gray degeneration in pos- 
terior and postero-median columns, and of posterior spinal nerve- 
roots. 

Symptoms. For clinical convenience the disease is divided into 
three stages — prodromal, maniacal, rarely melancholic, and the stage 
of dementia — although there is seldom a marked division between the 
stages. 

Prodromal stage may exist unrecognized for months or longer. It 
begins by an alteration in the habits and character of the individual, 
such as spells of irritability and obstinacy, which will not admit of 
contradiction or opposition, and there is a general feeling of elation 
and bien-etre, or egotism, shown by the exalted opinion of his own at- 
tainments and importance, and a great laudation of members of his 
family. He becomes boastful, untruthful, dishonest, and forgetful, 
neglecting engagements, business, self, and family. He frequently 
makes extravagant purchases and may waste large sums of money 
before his condition of irresponsibility is recognized, or may unwit- 
tingly resort to dishonest means to obtain money, as was shown in the 
case of an intelligent gentleman, who had squandered considerable 
money in unprofitable property, going to a railroad ticket-office, ask- 
ing for a ticket, remarking he was without cash, writing a check for 
one hundred dollars on a bank he had never had an account with, 
receiving ninety-nine dollars in change, immediately going to a 
jewelry store and purchasing a lady's gold watch and chain, paying 
sixty dollars for the same, and then going to a pawnbroker's and 
pledging the watch and chain for forty dollars, and the following day 
going to the same ticket-office and buying another ticket, such as 
he had purchased with the fraudulent check, and on being arrested 
protested he had done nothing dishonest. 

In many instances the patient develops ideas of an enterprising 
character, and resorts to all forms of expedients, which, to his mind, 
are going to improve his or his family's station and worldly condition. 
He determines to change his occupation or business, or attempts to 
instruct the authorities in what he conceives should be their duties. 

The moral lapses of paretics are most frequent during this stage, 
consisting of acts of theft, drunkenness, violent impulses, or indecent 



524 PRACTICE OF MEDICINE. 

assaults, in individuals who have possessed a good moral character. 
They become profane and vulgar, and often resort to sexual excesses. 
Associated with any of the above symptoms may be any one or more 
of the following physical conditions : tremor of the muscles about the 
month, naso-labial folds, and of the tongue, causing a slight slur or 
hesitating speech ; alterations in the pupils, or one pupil becoming 
somewhat larger than the other, or the pupils may be contracted to 
pin-head size with loss of accommodation ; attacks of vertigo, or epi- 
leptiform or apoplectiform seizures. The gastric, intestinal, hepatic, 
and nephritic secretions are disturbed, and there maybe headache 
and insomnia. After a variable duration, continuing in a mild degree 
for many months, is ushered in the — 

Second or maniacal stage, which is much the same as a severe 
attack of acute mania (megalomania), plus the physical signs of par- 
esis and the delusions or ideas of grandeur. The patient is excessively 
restless, boasting of his great wealth, intentions, prospects, and influ- 
ence ; one moment the most important of individuals, the next giving 
away thousands, and, if doubt is expressed as to his ability to do so, 
making it millions and often billions; presenting houses and lands, 
titles and offices, with unstinted liberality. It is to be noted that these 
so-called delusions of the paretic are in reality conceptions, or an ex- 
pansive delirium, for when contradicted the patient makes no effort 
to defend them ; they seem to be really assertions and reasserlions, 
continuing until incoherency restrains the airy imagination. If ques- 
tioned as to his health, replies, enthusiastically, "First-rate; never 
better in my life." The patient is sleepless, noisy, destructive, with 
attacks of blind, uncalculating violence, resisting all who attempt to 
restrain or molest him. The violent impulses of paretics are similar 
to the furious excitement of the post-epileptic maniac. 

The physical signs are more pronounced : the characteristic hesitat- 
ing and slurring speech increases ; the pupillary changes become 
more marked; the tremor of the tongue and lips increasing and 
spreading to the upper extremities ; the gait ataxic ; the patellar reflex 
iticreased, or, rarely, diminished; the sphincter of the bladder disor- 
dered, and there sometimes occurs paralysis of the anal sphincters. 

During the progress of the second stage are developed cerebral 
crises, — syncope, petit or grand mat, apoplectiform attacks, or para- 
lytic seizures. Few cases but show one or more of these conditions. 
There also occurs mvosis and loss of light reaction, and increased 



MENTAL DISEASES- 525 

wrist and elbow jerks. The maniacal stage is of shorter duration 
than any other, and is usually succeeded by the — 

Stage of dementia, the patient presenting all the evidences of failing 
mentality, with paralysis, trophic changes, as shown by the occur- 
rence of bed sores, cystitis, diarrhasa, and arthropathies, or Charcot's 
joints, the patient emaciating rapidly, death closing the scene within 
a few months. 

Rarely the maniacal stage is preceded or replaced by a condition 
of melancholia with expansive hypochondriacal delusions. In a few 
instances a genuine lucid interval has followed either the prodromal 
or maniacal stage. The spinal form of general paresis is fairly fre- 
quent, in which symptoms of spinal sclerosis are added to the mental 
ataxic phenomena of the usual form. 

"Of the many divisions of general paralysis into several clinical 
types, all of them naturally more or less arbitrary, I know no other so 
satisfactory as Meynert's eight" (Folsom) : 

1. Simple progressive dementia, with the usual motor impairment 
which accompanies it, but, excepting hypochondriacal depression, not 
necessarily exhibiting other mental symptoms than dementia. 

2. With the expansive delusions and the distinctive motor disturb- 
ances, which appear simultaneously and are progressive, constituting 
the " classic " form of general paralysis. The mental state is usually 
of self-satisfaction and exaltation, but there may be depression. 

3. Of the same type as the last, but failing its steadily progressive 
character through arrest of the active process. The remissions, which 
seldom last so long as a year, raise hopes of recovery, but still mani- 
fest unmistakable impairment of the reasoning faculties. The psychic 
disturbances are much greater than can be accounted for by the 
atrophy of the brain alone. 

4. Cases in which the characteristic exaltation and grand delusions 
reach such an astonishing height that manifest motor symptoms are 
looked for with confidence from day to day, and yet may not appear 
even for a year, any slight inco-ordination naturally being obscured 
by the general muscular disturbance. Meanwhile there may be such 
an improvement that the patient leaves the hospital for a while, once, 
rarely twice, on the responsibility of his family, but to return with 
marked motor as well as mental signs. 

5. Avery rare form, with alternate symptoms of exaltation and de- 
pression of the type of circular insanity. 



526 PRACTICE OF MEDICINE. 

6. With early furious delirium, painful hallucinations, confusion 
and incoherence somewhat resembling acute delirium 

7. Progressive general paralysis, in which the characteristic indica- 
tions appear secondary to other forms of insanity ; for instance, after 
paranoia or melancholia, first described by Hoestermann. 

8. The combined form with sclerosis in the whole cerebro-spinal 
tract, the symptoms of tabes or spastic paralysis predominating, ac- 
cording as the posterior or lateral columns of the spinal cord are 
chiefly involved. The ascending type, in which the cord is first 
affected, is rare. Optic neuritis, ending in atrophy and paralysis, 
especially of the ocular muscles, may precede marked mental symp- 
toms. 

Diagnosis. The development of the following symptoms re- 
moves all difficulties in diagnosis: Mental — alteration in character, 
loss of memory, defective will-power, changed moral sense, insomnia, 
violent impulses, melancholia or mania, unsystematized delusions of 
expansive character, with an exalted sense of well-being, gradually 
ending in dementia. Physical — hesitating, slurring speech; tremor 
of the lips, tongue, and upper extremities; pupillary changes, myosis, 
loss of light reaction ; exaggerated wrist-, elbow-, and knee-jerk ; 
attacks of syncope, vertigo, epileptiform or apoplectiform seizures, 
ataxia, trophic changes, and finally paralysis. 

Paralytic insatiity, organic dementia, or dementia paralytica, is not 
the same condition as general paralysis. It is the form of mental 
failure succeeding to gross brain lesions, such as apoplexy, tumors, 
softening, trauma, and sclerosis, associated with either hemiplegia or 
paraplegia. 

Prognosis. Unfavorable. Remissions very, very rarely occur. 
The duration of general paresis has been considerably lengthened 
by the hospital care of such patients now in vogue in all properly 
conducted insane hospitals. 

Treatment. The care of the general health and meeting symp- 
toms as they arise is all that can be done for general paresis. It 
is claimed that if the condition be recognized early in the prodromal 
stage, the stage of cerebral congestion or vasomotor paresis, much 
good may be accomplished, and, if not cured, may be held in 
check for a long period of time by the use of such drugs as digitalis 
or ergota. 

The maniacal excitement may be quieted by the use of the hot bath, 



MENTAL DISEASES. 527 

isolation (not seclusion), and the administration of small doses of 
hyoscince hydrobromas, which seems to exert an alterative action on 
the brain. For the insomnia, trional, gr. xx-xxx (1.3-2 Gm.), re- 
peated, is usually satisfactory. 

If a reliable syphilitic history is obtained, a thorough course of 
hydrargyrum and iodides should be administered. All means that 
promote the constructive metamorphosis are indicated in this most 
characteristic, progressive malady. 

DEMENTIA. 

Synonym. Acquired feeble-mindedness. 

Definition. A progressive general weakening of the mind, char- 
acterized by a loss of reasoning capacity, a diminution of feeling, a 
weakened volitional and inhibitory power, failure of memory, asso- 
ciated with lack of the power of attention, interest, and curiosity, in 
varying degrees, in an individual who at one time possessed these 
mental qualities. 

Forms. Acute dementia ; alcoholic dementia ; dementia apoplec- 
iica or paralytica ; dementia choreica ; chronic or secondary de- 
mentia ; de7nentia epileptica ; organic de7nentia ; partial dementia ; 
primary dementia ; dementia senilis ; dementia syphilitica ; dementia 
toxica. 

Causes. Deficient or feeble mental inheritance ; age ; atheroma ; 
following mania, melancholia, paranoia, and other forms of insanity ; 
the result of organic brain conditions ; alcoholism ; syphilis ; devel- 
opmental changes ; climacteric. 

Pathology. In acute dementia the changes are dynamic. In 
the priinary dementia there is probably atrophy of certain cells from 
overstimulation, the tissues being normally deficient. In secondary 
dementia the chief changes are : " alteration in the size of the vessels, 
owing to thickening and distention, the thickening being most marked 
in the deep layers, and in the walls of the vessels are fatty granules 
and haematoidin. The perivascular canals are enlarged. The changes 
in the cells may be described as deficiency in the number of pyra- 
midal cells, and a want of distinctness of outline and branches, the 
nuclei being larger, but changed in form, and only capable of slight 
carmine staining." In senile deme7itia there is general atrophy and 
degeneration of all the tissues of the brnin. 



528 PRACTICE OF MEDICINE. 

Symptoms. The onset, extent, and variety of the impaired 
mentality differ greatly. In some patients the evidences of the fail- 
ing mind are seen with the subsidence of the mania, melancholia, or 
other insanity, or soon after the development of the particular cause, 
while in another group of cases the development is slow and insidious. 
The difference in the intensity is marked ; in one case the changes 
being scarcely noticeable, the patient being simply less active than 
before, showing a slight indifference to his environment; while in 
others the pitients remain for hours alone, making no effort at move- 
ment and with little or no expression of the face ; while another class 
of cases are oblivious to the demands for food or drink, or the calls 
of nature, existing " in the darkness of perpetual intellectual and 
moral night." Between these symptoms are all varieties and degrees 
of mental enfeeblement, the physical symptoms of dementia varying 
with the particular cases, many enjoying the best of health, eating and 
sleeping well ; while others are always unwell, first one organ and then 
another being affected ; while another group suffer from chronic 
diarrhoea, which finally causes death. Dementia patients seem pre- 
disposed to tuberculosis, nephritis, and epilepsy. 

Acute de?nentia, or " stupor with dementia," is to be distinguished 
from " stupor with melancholia." The onset is rather sudden, with 
or without mania or melancholia, after some brain or bodily exhaus- 
tion, shock, or fright ; the patient, a young person, " is horror-stricken, 
paralyzed in mind, not merely deranged, not depressed or excited, but 
deprived of feeling and intellect ; his movements, if there be any, are 
automatic, but frequently he is motionless, standing or sitting, staring 
at vacancy for hours and days " (Blandford). These patients will 
not converse, and do not reply to questions, or but slowly, and in 
monosyllables, and their faces have a blank expression. One young 
man of twenty-three years, but three years in America, having an 
excellent musical education and remarkable skill as a piano per- 
former, being unable to secure pupils to instruct, was obliged to 
accept a position as a piano-player at a questionable summer-resort 
garden, where he contracted the alcoholic and sexual habit. His 
excesses increased, although never intoxicated ; he suddenly de- 
veloped symptoms of dementia, his mind becoming a complete 
blank, his circulation feeble, the surface cold; and he never offered 
to enter the dining-room, and yet attended to the calls of nature. 
He never spoke, and would remain alone and motionless for hours. 



MENTAL DISEASES. 529 

The sweetest music caused no movement showing intelligence. He 
was placed on the Mitchell rest treatment for six weeks, and, as his 
bodily condition improved, he was da'ly taken to the piano, and his 
fingers made to touch the keys. For weeks he showed no interest, 
when, slowly, one day he feebly ran his fingers over the keys, and 
from that day improved, until, within four weeks, his performance on 
the piano attracted wide attention, and, after recovery, which was 
complete, with no recollection of this sickness, he secured pupils and 
is to-day a successful teacher. He has assured me that he suffered 
no pain, no depression, but that all is a blank to him. 

Alcoholic dementia, the mental weakness resulting from excessive 
use of alcohol. Inebriety is a form of dementia, there existing an 
uncontrollable alcoholic habit, with weakened or absent will power 
and impaired mentality. Sutherland defines seven forms of insanity 
from alcoholic excess: (i) Intoxication; (2) delirium tremens ; (3) 
mania-a-potu ; (4) dipsomania ; (5) mania of suspicion ; (6) chronic 
alcoholism or dementia ; (7) general paralysis. 

Dementia apoplectica ox paralytica is an organic or terminal de- 
mentia due to the cerebral changes sometimes following a severe 
apoplectic seizure, and is usually associated with hemiplegia. 

Dementia choreica is a feeble-mindedness associated with chronic 
or hereditary chorea, or, in some cases, probably the result of chorea. 

Chronic dementia is the designation applied to all forms of dementia 
that have existed after one or more years. 

Dementia epileptica is the slow mental impairment resulting from 
long-continued and frequently occurring epileptic convulsions. 

Organic dementia, the mental deterioration resulting from gross 
organic brain lesions, such as sclerosis, tumor, embolism, or trauma. 
An intelligent machinist, aged forty years, fell a distance of twenty 
feet, striking on his head, but not causing any determined fracture. 
He was unconscious one week, and on slowly recovering it was no- 
ticed that there was some change of character, which has grown 
most decided, and is associated with persistent insomnia. He is rest- 
less, indifferent ; has loss of memory, is vulgar and profane, and in- 
clined to be talkative — opposite traits to his former self; has violent 
outbreaks, and has a delusion that he is to make a fortune out of a 
polish the formula for which was given him by God, but which he 
has mislaid. He cannot read or write, or, at least, he will never make 
the attempt. His physical condition is good. 
45 



530 PRACTICE OF MEDICINE. 

Partial dementia is an incomplete form of dementia in which the 
mental enfeeblement is associated with such a degree of intelligence 
and memory that the qualifying term " partial " is correct. This 
variety of dementia constitutes the majority of able-bodied, working, 
chronic insane patients seen in insane hospitals. 

Primary dementia is seen most frequently in the young, developing 
slowly and insidiously, without any symptoms of mania or melan- 
cholia, usually in a youth who has given promise of a bright future, 
by a slowly progressive indifference to his former occupation, studies, 
or surroundings, with developing carelessness and negligence of per- 
son and proprieties, no amount of external stimulus serving to rouse 
the receding mentality, until finally the downward course ends in 
dementia so decided that, but for the history of the individual, the 
case would be classed as congenital, or imbecility. 

Secondary, sequential, or chronic dementia, is the most common 
variety of mental impairment following mania, melancholia, and other 
insanities. According to Bevan Lewis, twenty per centum of manias 
and fifteen per centum of melancholias become permanent dements. 

Dementia senilis, the result of cerebral atrophy, with its consequent 
failing mental power. Loss of memory for recent events is one of the 
most common symptoms. The disease often begins as a senile 
mania, melancholia, or delusional insanity. A female aged sixty 
years, with intemperate history, was, on admission, exceedingly filthy 
and with many vermin. She says she has been persecuted in her 
poverty ; that she could not obtain goods from the store when she had 
no money, though the shopkeeper was rich ; that she was neglected 
by others ; insists that she ought to have been assisted ; is uncon- 
cerned with her surroundings ; is trifling and disrespectful, restless, 
moving her hands and body almost continually ; is childish and silly 
in manner, frequently laughing, claiming she is happy, and will not 
work; cannot remember her only sister's name or where she herself 
last resided. 

Dementia syphilitica is the feeble-mindedness resulting from cere- 
bral syphilis. This group of patients are always sanguine, and assert 
they are " all right," "never sick in my life," and yet unable to assist 
or care for themselves. This form of dementia has many symptoms 
akin to general paresis, and, indeed, is often termed " pseudo- 
paresis." 

Dementia toxica is the mental failure produced by the long- 



DISEASES OF THE SKIN. 531 

continued and excessive use of opium, cocaine, and chloral. Chronic 
plumbism is also given as a cause. 

Diagnosis. Acute dementia is often misnamed melancholia with 
stupor, but if the patient is in the teens the probabilities are that it is a 
case of the former, while if past forty it is almost certainly the latter. 

The distinction between dementia and idiocy or imbecility must 
always be determined. Esquirol's graphic description is well worth 
remembering : " The dement was a rich man who has become poor ; 
the idiot, on the contrary, has always been in a state of want and 
misery." 

Prognosis. Acute dementia is generally favorable. All other 
varieties are incurable. The average life-time of dements is placed at 
about twelve years, the great majority dying of tuberculosis, nephritis, 
or apoplexy. 

Treatment. Patients suffering from acute dementia should be 
placed on the Mitchell rest regime, with attention to all the secretions. 
If Dr. Mitchell's directions are carefully followed, the great majority 
of cases of acute dementia will recover within nine to twelve months. 

For the other forms of dementia, unfortunately, there is no cure, 
the treatment resolving itself into attention to the general health, with 
proper custodial oversight. 



DISEASES OF THE SKIN. 



DISORDERS OF SECRETION. 

SEBORRHCEA. 

Synonyms. Acne sebacea ; pityriasis ; tinea furfuracea ; dandruff. 

Definition. A functional disorder of the sebaceous glands of the 
skin; characterized by an excessive or diminished and abnormal 
secretion of sebaceous matter, forming upon the skin either as an oily 
coating or in crusts and scales. 

Varieties. Seborrhea oleosa ; seborrhcea sicca. 



532 PRACTICE OF MEDICINE. 

Causes. In newly born infants an increased secretion of seba- 
ceous matter — the vernix caseosa — is a physiological process. 

The origin of the disease is not fully understood, anaemia being a 
factor in many cases. Brunettes are more often affected than blondes, 
and women more frequently than men. 

Pathology. Seborrhcea is a functional derangement of the 
sebaceous glands ; if it be allowed to become very chronic, there 
occurs atrophy of the glands and follicles. 

Symptoms. The affection may occur upon any portion of the 
body, its most frequent seat being, however, the scalp {seborrhcea capitis 
or pityriasis capitis), and next in frequency the face {seborrhcea faciei). 

Seborrhcea oleosa appears as an oily, greasy coating upon the skin, 
without hypersemia, and not attended with itching. The secretion is 
of an oily character, the quantity at times being so great as to collect 
in minute drops of a clear, yellowish fluid upon the surface. 

The most common seat for this variety is the face — seborrhea faciei 
— and nose — seborrhea nasi. 

Seborrhcea sicca consists in the formation of dry, more or less 
greasy, masses of scales or crusts of a grayish, yellowish, or brownish- 
yellow color, having a strong tendency to adhere to the skin, and 
attended with decided itching. Occurring upon the scalp — seborrhcea 
capitis — it is a frequent source of premature baldness. 

Diagnosis. Seborrhcea capitis may be mistaken for dry eczema, 
but the former is always a d?y disease, while in eczema moisture has 
occurred at some period of the affection. The scales in seborrhcea 
are very abundant and pale ; in eczema the scales are scanty and 
reddish, the parts irritated, infiltrated, and thickened. 

Seborrhcea sicca and psoriasis have many points of resemblance, 
whether occurring on the scalp or on the body. In seborrhcea the 
scales are minute or caked, grayish or yellowish in color, of an 
unctuous feel, and usually uniformly diffused. In psoriasis the scales 
are very dry, abundant, thick, white, irregularly dispersed, with inter- 
vening healthy skin, and the surface beneath the scales is always reddish 
and inflamed. The clinical histories of each are entirely different. 

Prognosis. If properly treated, favorable, although the affection 
is obstinate to eradicate. 

Treatment. The secretions require attention. If anaemia be 
present, ferrum and arsenicum are indicated. The following formula 
of Sir Erasmus Wilson, and lauded by Hebra, is valuable : 



DISEASES OF THE SKIN. 533 

R. Vini ferri, f^iss 45. Cc. 

Syr. simplicis, 

Liq. potassii arsenit., . . . aa f.^ij aa 8. Cc. 

Aquae destil., f^ij 60. Cc. M. 

Sig. — Teaspoonful three times a day, well diluted. 

Duhring recommends calcii suiphidum, gr. ^-\ (0.0065-0.013 Gm.), 
several times daily. 

Local measures are the most important in seborrhcea. For sebor- 
rhea capitis the following plan will usually be successful : 

The scales are to be thoroughly moistened with either oleum olive, 
oleum morrhucB, or adeps, to facilitate their removal ; it is best applied 
at night and the head covered with a flannel or other cap ; or R . 
Liq. boro-glycerini, f^ij (8 Cc.) ; Aquae rosae.f^viij (240 Cc); mix and 
apply on gauze. As soon as the crusts are well soaked they should be 
removed by washing with soap and warm water, or equal parts of 
soap, glycerine, and water, or the following will be found valuable : 

R. Tinct. sapo mollis, f.T^ I2 °- Cc. 

Spts. vini rect., f^ij 60. Cc. M. 

Solve et filtra. 

Sig. — Dilute and use as a soap-wash or shampoo. 

The scalp is to be thoroughly cleansed of either of the above by 
again washing with warm water, and then dried by means of a soft 
towel. Then should be applied some oily or fatty substance, depend- 
ing upon the condition of the scalp. 

If much irritation, either vaselinum or oleum amygdala expressutn. 
If no irritation be present, a stimulating preparation will be found of 
great benefit. Either of the following may be used : 

R. Tinct. cantharidis, f ^ iij 12. Cc. 

Tinct. capsici, f 3 iij 12. Cc. 

01. ricini, fgij 8. Cc. 

Alcoholis, fifij 60. Cc. 

Spt. rosmarini, f^j 30. Cc. M. 

— {Duhring.) 
Or— 

R . Bismuthi subnitratis, gj 4. Gm. 

Ung. hydrargyri ammoniat., . . Zij 8. Gm. 

Ung. aquae rosae, ad 3 j ad 30. Gm. M. 

The above should be repeated every day or two, as the symptoms 
may require, until a cure is effected. 



534 PRACTICE OF MEDICINE. 

The boroglyceridum mixture mentioned above or the following com- 
bination is useful for dandruff: 

& . Ammonii hydrochlorat. , . . . . gr. x o. 65 Gm. 

Glycerini, f^j 30. Cc. 

Aquse rosse, f^v 155. Cc. M. 

SiG. — Apply to head. 

Seborrhcea occurring on other portions of the body is to be treated 
upon the same general principles. 



COMEDO. 

Synonyms. Acne punctata nigra ; black-heads or worms. 

Definition. A disorder of the sebaceous glands; characterized 
by retention in the excretory ducts of an inspissated secretion which 
is visible upon the surface as yellowish or whitish pin-point and pin- 
head-sized elevations, containing in their centres blackish points. 

Causes. The exact etiology is unknown. Among the causes as- 
signed are anaemia, menstrual disorders, urethral irritations, dyspep- 
sia, and constipation.. 

Pathology. Comedo is an affection of the sebaceous glands and 
ducts, consisting of an accumulation of sebum and epithelial cells in 
the glands and follicles, dilating the ducts to such an extent as to pro- 
duce the point or elevation upon the surface. The obstructed gland 
may relieve itself, or it may continue distending until a papule is 
formed. The duct sometimes contains small hairs, and also the 
microscopic mite, demodex folliculorum, — having a length of from 
Y^y to y 1 ^ of an inch, and breadth of about -gfo of an inch, — which 
was at one time supposed to be the cause of the affection. 

Symptoms. A chronic affection, observed for the most part 
on the face, neck, chest, and back. Each elevation or black- 
head or point is designated a comedo ; if a number, comedones. 

Each comedo is small, varying from a pin-point to a pin-head in 
size, having a brownish or blackish appearance, from the dust or dirt 
that has adhered to the unctuous surface. If they form in great 
numbers upon the face they are disfiguring, giving the individual the 
appearance of having had minute grains of powder implanted in the 
skin. There are no evidences of inflammation unless acne is asso- 
ciated, but, on the contrary, the skin has a dirty, greasy, unwashed 
appearance. 



DISEASES OF THE SKIN. 535 

Diagnosis. There is no condition resembling comedo, so that its 
recognition is easy, unless complicated with acne ; but even then the 
inflammatory appearance of acne should prevent error. 

Prognosis. Favorable, although often remarkably obstinate. 

Treatment. Derangement of any of the functions of the body 
should be corrected, and strict attention be given to the rules for pro- 
moting the general health. 

Local measures are usually sufficient. The parts should be thor- 
oughly softened by bathing with soap and warm water, when the 
comedones are removed by friction with a Turkish towel, pressure 
between the thumb-nails, the application of a watch-key, or the in- 
strument known as the " comedo extractor," and their return pre- 
vented by an unguentum medicated, to meet the indications, with 
either sulphur, alkalies, or hydrargyrmn. 

Dr. Shoemaker recommends the following formula : 

B; • Thymol, gr. x 0.65 Gm. 

Acidi borici, 3 ij 8. Gm. 

Aquae hamamel. Virg. dest., . . f.^iv 15. Cc. 

Aquae rosae, f^j 30. Cc. 

Sig. — Mop well over the surface once or twice daily. 



MILIUM. 

Synonyms. Grutum ; tubercula miliaria or sebacea ; acute punc- 
tata albida. 

Definition. An accumulation of sebum in the sebaceous glands 
which are minus their excretory ducts ; characterized by the forma- 
tion of small, roundish, whitish, sebaceous, non-inflammatory eleva- 
tions, situated immediately beneath the epidermis. 

Cause. The origin of the affection is not understood. 

Pathology. The sebaceous gland is distended with the sebum, 
which is unable to escape, owing to the obliteration of the duct, nor 
can the contents be squeezed out, as no sign of aperture is to be 
found, the formation being completely enclosed. 

Rarely the retained secretion undergoes a metamorphosis into hard, 
calcareous, stone-like masses — sebaceous concretions or cutaneous 
calculi. 

Symptoms. Milia may occur upon any portion of the body; 
their usual seat, however, is upon the face, forehead, and about the 



536 PRACTICE OF MEDICINE. 

eyes. They form gradually, are about the size of a millet seed, of a 
whitish, pearl, or yellowish color, hard, and of a rounded shape, giv- 
ing the sensation to the touch of hard bodies embedded in the skin. 
They are not associated with inflammatory symptoms. 

Diagnosis. Milium and comedo are somewhat similar in ap- 
pearance ; the differences are that in milium the sebaceous gland is 
distended without an opening, while in comedo the duct of the gland 
is always patulous upon the surface. Milium usually exists singly, 
the skin looking normal ; while comedo is more general, the surface 
having a soiled and greasy appearance. 

Prognosis. Favorable. 

Treatment. As a rule, no treatment is needed, the number being 
few and their presence of no consequence. 

If their removal be desirable, two modes suggest themselves : one, 
to open the cyst with a fine-bladed bistoury, and turning the contents 
out, destroying the remaining sack by the application of either tinc- 
tura iodi or acidum chromici ; or the cyst may be destroyed by 
electrolysis. 



SEBACEOUS CYST. 

Synonyms. Wen ; sebaceous tumor ; encysted tumor. 

Definition. A distention of the sebaceous gland and duct, with 
hypertrophy of the walls, forming a thick, tough sac or cyst : char- 
acterized by a firm or soft, more or less rounded tumor, having its seat 
in the skin or subcutaneous connective tissue. 

Cause. Unknown. 

Pathology. Hypertrophy of the gland and duct walls, the result 
of pressure from the accumulated contents, which consist of the 
altered products of the sebaceous secretion. 

Symptoms. The development of wens is slow and insidious. 
The localities where they are most commonly developed are the scalp, 
face, back, and scrotum. 

The tumors occur singly or in numbers, in size from a pea to a 
walnut, or larger, in shape either rounded, flattened, or semi-globular ; 
in consistency they are either hard or soft and doughy ; they are 
freely movable and painless. 

Diagnosis. Sebaceous cysts may be confounded with fatty tumors. 

Treatment. Excision and careful and thorough dissection of the 
cyst. 



DISEASES OF THE SKIN. 537 

HYPERIDROSIS. 

Synonyms. Hydrosis ; ephidrosis ; idrosis. 

Definition. A disorder of the sweat glands, characterized by an 
increased secretion of sweat. The sweating may be either general or 
partial, but unilateral sweating, or hyperidrosis, is the condition here 
considered. 

Causes. Often undetermined ; occasionally inherited ; diseases 
of the brain and disorders of the sympathetic nervous system. 

Pathology. A functional derangement of the sudoriparous 
glands, over which the vasomotor system has control. The char- 
acter of the secretion, chemically, may not differ from the normal. 

Symptoms. Hyperidrosis may be acute or chronic, the amount 
slight or large, being constant or paroxysmal, the extent general or 
local, and it may or may not be symmetrical. 

Bromidrosis is the designation when the secretion has an offensive 
odor. 

Chromidrosis is the designation when the fluid poured forth is vari- 
ously colored. 

Uridrosis is the designation when the excretion from the sweat- 
glands contains the elements of the urine, and particularly urea. 

Phosphoridrosis is the designation when the perspiration appears 
luminous in the dark. 

Local hyperidrosis occurs most commonly upon the palms, soles, 
axillae, and genitalia. 

Hyperidrosis of the palms may be so profuse that the fluid accumu- 
lates and keeps the parts constantly macerated, the wearing of gloves 
being impossible, for as soon as the parts are wiped dry they are again 
bathed in the secretion. Jamieson states that hyperidrosis of the 
hands is very common in those who are daily excessive spirit drinkers. 

Hyperidrosis of the soles is a disagreeable and often distressing 
condition, as the socks and shoes become saturated, and thus keep 
the soles constantly bathed, allowing the macerated epidermis to peel 
off, leaving a more tender skin exposed, causing pain and distress 
when walking. The maceration of the epidermis, the secretion about 
the toes, together with the moisture of the socks and the soles of the 
shoes, promote the rapid development of the bacteria foetidum ; all 
these together produce a most disagreeable, disgusting, and persistent 
odor, which is termed bromidrosis pedum. 
46 



538 PRACTICE OF MEDICINE. 

Hyperidrosis of the genitalia attacks males more particularly, giving 
rise to a disagreeable, penetrating odor. 

The sweating may be limited to one side — unilateral hyperidrosis. 

Prognosis. The majority of cases are extremely intractable. 
Recovery, however, is the rule. 

Treatment. The general condition of the patient must receive 
proper attention. Atropines sulphas, gr. T 2o~eV (0.00054-0.001 Gm.) 
twice daily, is often serviceable. Ergota in pill or solution is useful. 
Agaricina, gr. \ (0.011 Gm.), has been recommended. 

Local treatment is the most valuable, however. 

The parts should be cleansed and immediately dried, and then 
dusted with some one of the numerous dusting powders. The follow- 
ing is a valuable powder : 

R . Acidi salicylici, gr. xx 1.3 Gm. 

Zinci oleat., ^j 30. Gm. M. 

Perhaps the very best local application is tinctura belladonna, 
either diluted or full strength. Aristol as a dusting powder is very 
satisfactory. 

In hyperidrosis of the palms and soles, the following are valuable, 
first washing the parts with a weak solution of aciduni carbolicum : 

R. Acidi salicylici, 55 ss 2. Gm. 

Cretse praep., %} 30. Gm. 

Aluminis exsic, Jj 30. Gm. 

M. et powder finely. 

SiG. — Apply to parts with puff-ball. 



O 



R . Acid, salicylici, 3 parts 

Pulv. amyli, 10 parts 

Pulv. soapstone, 87 parts. M. 

SiG. — Sift into shoes and stockings. 

Or— 

ri . Sulphur, lotum., gr. xxx 2. Gm. 

Pulv. arrowroot, giv 15. Gm. 

Acid, salicylici, gr. vij 0.45 Gm. M. 

SiG. — Dust over feet and between toes. 

Or— 

&. Potassii permanganat., gr. ij 0.13 Gm. 

Aqux destil., fjj 30. Cc. M. 



DISEASES OF THE SKIN. 539 

A saturated solution of acidum boracicum, alone orin powder, with 
equal parts of' ' aceta7iilidinn y applied frequently to the hands and 
feet, often proves curative. 

For obstinate cases, involving the palms or soles, the following plan 
of treatment, as suggested by Hebra, will be found of the greatest 
service. It is imperative that the various steps be closely followed : 

" The parts are to be cleansed with water and soap, and the follow- 
ing ointment applied on pieces of cloth cut to the size of the region. 
Lint smeared with the ointment is also to be placed between the toes 
or fingers, so that every portion of the skin may be covered with a 
layer of the ointment. 

R . Emplast. diachyli, ^iv 1 20. Gm. 

Olei olivae, f^i v I2 °- Cc. 

The plaster to be melted and the oil added and stirred until a homogeneous 
mass results. 

Sig. — To be used on cloths. 

" The cloths are to be changed every twelve hours, when the parts 
are not to be washed, but rubbed with dry lint and starch dusting 
powder, after which new dressings are again to be applied in the 
same manner. This proceeding is to be continued from one to two 
weeks. When the disease is upon the soles, the patient may walk 
about in loose shoes." After a week or ten days the ointment may 
be discontinued, but the dusting powder is to be used for a consider- 
able period. If relapses occur, the original treatment should again 
be instituted. 

Painting the soles and under and between the toes with a ten 
per centum solution of formalin, morning, noon, and night, has given 
good results in a number of instances. A few drops of the solution 
may be put in the boot or shoe. 

SUDAMINA. 

Synonyms. Sudamen ; miliaria crystallina (Hebra). 

Definition. A non-inflammatory affection of the sweat-glands ; 
characterized by the rapid development of millet-seed-sized, translu- 
cent, whitish vesicles in great numbers upon any portion of the body. 

Causes. A high bodily temperature, causing unusual activity of 
the sudoriparous glands. 

Pathology. The glands being excited beyond their capacity for 



540 PRACTICE OF MEDICINE. 

normal excretion, the excessive fluid, instead of escaping upon the 
surface, from some cause collects between the layers of the epidermis, 
in the form of minute, translucent pin-point-sized vesicles. 

Symptoms. An ephemeral rash. Each minute vesicle is dis- 
tinct, but they exist in great numbers, very closely resembling drops 
of free sweat. They develop rapidly, never coalesce, become puri- 
form, or rupture. Fresh crops form from time to time. Their dura- 
tion is transitory ; the fluid is absorbed, the covering of each dries, 
forming a thin, delicate membrane, which disappears as a slight 
desquamation. 

Treatment. The treatment is that of the disease with which they 



ANIDROSIS. 

Definition. A functional disorder of the sweat-glands; charac- 
terized by a diminished or insufficient secretion of sweat. 

Causes. The result of a congenital deficiency of the sweat gland- 
ular apparatus. Local anidrosis may result from injury to a nerve, 
during the course of chronic diseases of the skin, as ichthyosis, 
eczema, psoriasis, lepra, and elephantiasis arabum. In rare cases an 
individual ceases to sweat entirely at times ; in such cases the general 
health is impaired, and during the hot season much suffering may 
result. 

Treatment. Means to promote the activity of the skin and glands 
is the indication, such as the ingestion of large quantities of water, 
hot baths and steam baths, friction, and the use of sudorifics, the most 
valuable of which is pilocarpus. 



HYPEREMIAS OF THE SKIN. 

ERYTHEMA SIMPLEX. 

Definition. An acute affection of the skin, in which occurs an 
abnormal quantity of blood in the dermal vessels ; characterized by 
discoloration, which disappears upon pressure and with more or less 
local increase of temperature. 

Varieties. Idiopathic erythema; symptomatic erythema. 

Causes. Idiopathic erythema ; heat, cold, pressure, friction, or 
the contact of irritants, such as mustard, arnica, and dyestuffs. 



DISEASES OF THE SKIN. 541 

Sympt07natic erythema occurs most frequently in childhood, from 
diseases of the stomach and intestines ; during the course of the 
various exanthemata. 

Symptoms. A more or less rapidly developed redness of the 
skin, varying in color from pink or light red to dark red, which dis- 
appears upon pressure, to rapidly return again. The extent and form 
of the congestion varies according to the cause, at times being as 
small as a coin and isolated, and again diffused over a large area. 
The temperature of the congested part is slightly above the normal. 
Slight itching and burning are, usually, associated with the discolora- 
tion. 

Diagnosis. Erythema resembles acute dermatitis in color, but 
the subjective symptoms of the latter are so decided that an error 
should not occur. 

Treatment. Controlled by the cause, which should be removed, 
and the local application of some one of the various dusting powders. 



ERYTHEMA INTERTRIGO. 

Definition. An acute congestion of the skin, characterized by 
redness, heat, increased perspiration, and an abraded surface, with 
maceration of the epidermis. 

Causes. In the fleshy, from contact or friction of opposing sur- 
faces exposed to warmth — chafing. In children and infants, contact 
of moist clothing; also disorders of digestion. 

Symptoms. Parts where the natural folds of the skin come in 
contact with one another, as the nates, perineum, groins, axillae, and 
beneath the mammas, in the fleshy and in infants, become red, hot, 
Painful, and have an increased flow of perspiration, which in turn 
softens the epidermis, giving rise to an acrid, mucoid fluid. If not 
checked by the removal of the cause and the application of the dust- 
ing powders, inflammation — dermatitis — results. 

Treatment. The congested parts should be thoroughly washed 
with water and Castile soap, or with bran-water, and carefully dried 
with a soft towel. The opposing folds of the skin are to be kept sep- 
arated with lint or soft linen, the parts first covered with cretce prce- 
parata, zinci oxidum, bismuthi subnitras, amylum, lycopodium, or 
buckwheat-flour. 



542 PRACTICE OF MEDICINE. 

INFLAMMATIONS OF THE SKIN. 

ECZEMA. 

Synonyms. Tetter ; salt rheum ; scall. 

Definition. A non-contagious inflammation of the skin, charac- 
terized by any or all of the results of inflammation, at once or in suc- 
cession, such as erythema, papules, vesicles or pustules, accompanied 
by more or less infiltration and itching, terminating in a serous dis- 
charge, with the formation of crusts, or in desquamation. 

Forms. Acute ; chronic. 

Varieties. Eczema erythematosum ; eczema papillosum ; eczema 
vesiculosum ; eczema pustulosum ; eczema rubrum ; eczema squamo- 
sum ; eczema fissum ; eczema verrucosum ; eczema sclcrosum. 

Causes. Eczema attacks persons in all spheres — the rich, the 
poor, the infant or the aged, and males or females. Many families, 
especially those having the " catarrhal predisposition or peculiarity 
of constitution," seem more liable ; indeed, it appears probable that 
a predisposition to eczema may be transmitted from parent to child. 
Among the causes suggested are : dentition, improper food, gastro- 
intestinal disorders, and imperfect elimination of products of waste ; 
intestinal parasites, deficient urinary secretion, the rheumatic and 
gouty diatheses, vaccination, prolonged contact of hot fomentations, 
heat and cold, and contact with the poison vine (rhus toxicodendron) 
and poison tree (rhus venenata). 

Pathology. Eczema is a catarrhal inflammation of the skin — 
a dermatitis, with superficial serous exudation. There is first hyper- 
emia, or congestion of the vessels of the skin — eczema erythemato- 
sum, when uniformly distributed, eczema papulosum, when the con- 
gestion is limite.d to distinct points. The hyperaemia is soon followed 
by a serous exudation. If the superficial exudation be profuse enough 
to form small drops, and if the epidermis possess sufficient resisting 
power not to give way immediately before it, vesicles form, producing 
the variety known as eczema vesiculosum ; if the vesicles contain a 
large admixture of young cells, so that the serum be turbid, yellow, 
and purulent, the vesicles become pustules, termed eczema pustulo- 
sum ; if the serous exudation be not sufficient to either elevate or 
break through the epidermis, instead of either vesicles or pustules 
forming, there occur dry scales, rising from the reddened skin — 



DISEASES OF THE SKIN. 543 

eczema squamosum. When the exudation is sufficient to detach the 
epidermis, thus exposing the red and moist corium, it is termed eczema 
rubrum. 

In chronic eczema the skin is subacutely inflamed ; is very much 
thickened, hardened, and infiltrated with cells which extend through- 
out the entire corium, even into the subcutaneous connective tissue. 
The papillae are enlarged and at times may be distinguished with the 
naked eye. Pigmentation may take place in the deep layers of the 
rete and in the corium, especially about the vessels. 

Symptoms. Eczema is the most common of all cutaneous affec- 
tions, with symptoms varying in accordance with the particular 
variety of the affection and the location, although the general char- 
acteristics of a catarrhal inflammation are present in all ; these are 
redness, either limited or diffused ; heat, of the part affected ; swell- 
ing, the result of the serous exudation, giving rise either to a dis- 
charge (weeping), with subsequent crusting, or to the deposition of 
plastic material. The most constant, annoying, and troublesome 
symptom is the itching, or, at times, burning, which varies from that 
which is simply annoying to that which is almost unendurable. 

Eczema runs its course either as an acute affection, lasting a few 
weeks, not to return, or to return acutely at wide intervals, or, as is 
much more frequently the case, it assumes a chronic state, continuing 
with more or less variations for months, years, or even a life-time. It 
may appear upon any portion of the body or involve the whole in- 
tegument {eczema universale). The varieties are named in the order 
the lesions assume at their commencement. 

Eczema Erythematosum. An erythema or redness of the 
surface, with a yellow tinge. The size of the macule may be very 
small or quite extensive, with irregular outlines. There maybe slight 
swelling of the patch, but no discharge occurs unless it be where two 
surfaces come into contact {ecze?na intertrigo), as about the genitalia. 
Cases without discharge are covered after a few days with a thin film 
of dry, enfoliating epidermis or scale {eczema squamosum). When a 
discharge (weeping) or moisture occurs, it is followed with more or 
less crusting. 

Intense itching \s a constant symptom. 

Eczema Papillosum, or Lichen Simplex. This variety of 
eczema appears in the form of small, rounded papules, the size of a 
pin-head, of bright-red or, at times, dark-red color; they may be either 



544 PRACTICE OF MEDICINE. 

discrete or confluent. In some cases all, while in others a greater or 
less number, of the papules pass into vesicles and run much the same 
course as vesicular eczema. The itching is of the 7nost intense char- 
acter, leading to severe scratching, by which the summits of the 
papules are torn, causing them to bleed, the blood forming dark-red 
crusts. 

Eczema Vesiculosum. Begins with burning, pain, redness, and 
swelling, followed by an immense number of minute vesicles, either 
discrete or confluent, rapidly distending with a clear or yellowish 
fluid and attended with intense itching. Soon the vesicles rupture, 
the fluid rapidly diffusing over the surface and drying into yellowish, 
honey-like crusts. New crops of vesicles soon follow, or if subsequent 
vesications do not occur, the fluid rapidly diffuses over the excoriated 
surface, which also, in turn, dries into large, yellowish crusts. After 
a variable time the various symptoms gradually subside. 

Itching is the most prominent subjective symptom, is intense, and 
gives rise to an irresistible desire to scratch. 

All portions of the body are liable to this variety of eczema, the 
most frequent location, however, being the face, and when occurring 
in children is commonly known as crusta lactea. 

Eczema Pustulosum, or Eczema Impetiginosum. This 
variety usually begins as vesicular eczema, the fluid rapidly changing 
to pus. After a short period, during which the pustules have increased 
in size, they burst and the escaped fluid forms thick, greenish-yellow 
crusts, which, in turn, rapidly dry and fall off, or crumble away. 

The location of this variety is most usually upon the scalp and face. 
It is stubborn to treatment. Itching is a prominent symptom. 

Eczema Rubrum, or Eczema Madidans. This is a variety 
only from a clinical standpoint. It may result from any of the fore- 
going varieties. The surface of the skin is inflamed and infiltrated, 
red, moist, and weeping, the profuse serum rapidly drying into thick, 
yellowish, greenish, or brownish crusts, the color depending upon the 
character of the fluid, which may be serum, pus, or blood from the 
exposed and lacerated corium. The crusts adhere closely and firmly 
to the part, and unless removed by mechanical means may remain 
indefinitely, the disease pursuing its course beneath. Eczema rubrum, 
or madidans, '* then, presents two appearances — as it occurs with its 
crust, and as it exists without this covering. In the one case the 
skin itself is altogether obscured by a dirty, yellowish, or brownish 



DISEASES OF THE SKIN. 545 

crust; in the other the skin presents a bright or violaceous red, punc- 
tate, wounded surface, deprived in great part of its epidermis, and 
exuding a scanty or profuse, clear or opaque, syrupy, yellowish fluid. 
Sometimes this is streaked with blood." The itching and burning 
are severe. It may develop upon any portion of the body, but is 
most commonly seen upon the legs, particularly in elderly people. 
Its course is chronic and increasing in severity. 

Eczema Squamosum. This is also a clinical variety. It results 
from the erythematous, vesicular, pustular, or papular varieties of the 
affection, but more particularly the first named. A typical case pre- 
sents itself in the form of variously sized and shaped reddish patches, 
which are dry, or more or less scaly, the skin being more or less infil- 
trated or thickened. Its course is usually chronic. 

Eczema Pissum, or Rimosum. Another clinical variety. 
During the progress of the erythematous, vesicular, or pustular varie- 
ties of eczema, cracks or fissures result when the lesion occurs upon 
regions subject to constant motion, such as between the fingers, toes, 
nates, and the various joints. At times the fissures are extensive and 
deep, and of a bright-red color, showing the true skin, and intensely 
painful upon motion. Chapped hands are typical instances of fissured 
eczema. 

Eczema Sclerosum. This variety of eczema, occurring most 
commonly on the palms, soles, and finger-tips, is characterized by 
hypertrophy of the papillae, showing itself as hard, thickened, infil- 
trated, localized patches, which are most apt to crack (eczema fissum). 

Eczema Verrucosum, or Papillomatosum, differs from the 
foregoing in that the thickened, infiltrated patch has a warty, verru- 
cous appearance. Its course is chronic. 

Eczema Acutum et Chronicum. The line which divides 
these two conditions is drawn by means of the clinical and patho- 
logical features. The course of eczema, in the majority of instances, 
is chronic. It may be said that so long as the general inflammatory 
symptoms are high and the secondary changes slight, the affection is 
acute, and that when the process has settled itself into a definite line 
of action, continually repeating itself and accompanied by secondary 
changes, it is chronic. 

Diagnosis. The many varieties in which eczema manifests itself 
renders the diagnosis a matter of importance. The following charac- 
teristic features of eczema are of value in arriving at a diagnosis: 



546 PRACTICE OF MEDICINE. 

infianunation, swelling, and cede?na, thickening from cell infiltration, 
redness, the discharge of moisture, followed by crusting, on removal 
of which a moist surface is presented, and itching and burning. 

Erysipelas may be confounded with erythematous or vesicular 
eczema. The points of difference are the fever and other general 
disturbances. The deep-seated inflammation of the skin, rapidly 
spreading, with heat, swelling, and oedema without moisture, giving 
the surface a deep-red, shining, and tense appearance, are character- 
istics of erysipelas and very different from eczema. 

Herpes and vesicular eczema bear some resemblance to each other ; 
herpes zoster is distinguished by the neuralgic pains which are asso- 
ciated with it and are never associated with eczema. The other varie- 
ties of herpes occurring about the face and genitalia run their course 
in a few days, while eczema is of much longer duration and has a 
discharge followed by crusting. 

Seborrhosa of the scalp and squamous eczema of the same region 
closely resemble each other. In eczema, however, the skin is more 
or less red, inflamed, and thickened, and the scales larger, less abun- 
dant and less greasy and drier than seborrhcea. In eczema the 
scales are usually seated upon a circumscribed patch, while in sebor- 
rhcea, as a rule, they cover the scalp uniformly. Itching occurs with 
both disorders. The history of the two affections should be of material 
aid in rendering the diagnosis clear; still, however, in many cases 
the diagnosis is difficult. Both are frequent affections. 

Psoriasis should never be confounded with a typical case of eczema, 
but chronic eczema, with infiltrated, inflammatory, scaly patches, fre- 
quently looks very much like psoriasis. 

Treatment. There is no specific. The indications are for the 
removal of the cause, where it can be ascertained, and attention to the 
general health. The diet should be of the most nutritious, but easily 
digestible, character. Fresh air and moderate exercise are also essen- 
tial elements in the treatment, together with attention to the secre- 
tions, particularly of the kidneys. If the bowels be sluggish, much 
benefit follows the use of such laxative mineral-spring waters as the 
Hathorn, or Hunyadi Janos, or a morning dose of 7nagnesii sulphas. 
For children, syrupus rhei, to which maybe added magnesia ; or, 
what is perhaps more efficient, a small dose of hydrargyri chloridum' 
mile. If the urinary secretion be small and the urine heavy, use 
should be made of full doses of potassii acelas, and large draughts of 



DISEASES OF THE SKIN. 547 

water. If either a rheumatic or gouty condition exist, lithium salts, 
to which may be added vinum colchici seminis. If a scrofulous ten- 
dency exist, use oleum morrhuce and syrupus ferriiodidi. If anaemia, 
ferrum, quinina, strychnina, and the mineral acids, or syrupus hypo- 
phosphitum compositus, are indicated. If the disease shows a ten- 
dency to linger or relapse, arsenicum is a valuable agent, but is to be 
avoided in the acute condition. In the pustular variety calcii sul- 
phidum is often useful in doses from gr. ^ to % (0.003-0.016 Gm.). 
Dr. Morrow strongly recommends the Viola tricolor (wild pansy), 
particularly for cases of eczema of the scalp, or crusta lactea. 

Locally. The most important treatment for all the varieties of 
eczema is with local remedies, suiting the appropriate ones for 
each particular case, as no one combination is applicable for all 
varieties. It may be stated as a principle, that nothing irritant is 
ever to be applied to the surface in acute eczema, and that in the 
chronic form nothing can hardly be too stimulating. The too frequent 
washing or general baths are to be avoided, as they have a tendency 
to macerate the already softened epidermis. For cleansing purposes, 
in the majority of instances, ordinary Castile soap is sufficient. 

Crusts and scales are nearly always present in eczema, and are to 
be removed before medicaments can be successfully applied. Their 
removal is to be secured by saturation with oily preparations, a starch 
or other mild poultice, or a saturated solution of acidum boricu?n or 
diluted boroglyceridum. After their removal the parts are to be 
cleansed with Castile soap and water. 

For acute erythematous or vesicular eczema, use but little, or, what 
is better, no soap or water; instead, covering the parts with a dusting 
powder, one of the most useful being acidum boricum, or — 

R . Pulv. camphorae, gj 4. Gm. 

Zincioleat., £ij 8. Gm. 

Pulv. amyli, Jj 30. Gm. M. 

Sig. — Dusting powder. 

For acute vesicular eczema, Dr. J. C. White recommends bathing 
the affected part with lotio nigra (hydrargyri chlor. mite, gr. viij 
[0.5 Gm.], liquor calcis, f ^ j [30 Cc.]), full strength, or diluted with 
equal parts of lime-water, applied by means of a sponge or a piece of 
cloth for ten or fifteen minutes at a time, and at intervals of a few 
hours or longer, the sediment being allowed to remain on the skin ; 



548 



PRACTICE OF MEDICINE. 



after which unguentum zinci oxidum is to be gently rubbed over the 
part. As a rule, the itching and burning are relieved at once, and 
the affection often arrested. Good results follow the application of a 
saturated solution of acidum boricum. 

There are cases which do better from the application of ointments, 
of which the following is valuable : 



B. • Zinci oleat, . . 

Olei olivse, . . . 

M. et ft. unguentum. 



3 1V 
f3iv 



15. Gm. 
15. Cc. 



Or, bismuth oleate, made according to the following formula of Dr. 
McCall Anderson : 



R . Bismuthi oxidi, 
Acidi oleici, . 
Cerae albae, 
Vaselini, . . . 
01. rosae, . . 



3J 


4. Gm. 


l\ 


30. Gm. 


3 "J 


12. Gm. 


31X 


36. Gm. 


"tfj 


0.12 Cc. 



M. 



If the discharge be excessive, the following formula of Professor 
Bartholow is valuable : 



R. Plumbi acetat., ^ss 16. Gm. 

Pulv. camphorae, gr. xv I. Gm. 

01. amygdal., f % ij 60. Cc. 

Cerat. flav., Jj 30. Gm. 



M. 



The late Dr. Frank Maury was partial to the following formula in 
vesicular eczema : 

]£. Hydrargyri chlor. mitis, . . . . gr. xx 1.3 Gm. 

Ung. zinci oxid. benz., Jj 30. Gm. 

M. et ft. unguentum. 

For eczema papillosum the following lotions are particularly valu- 
able : 

&. Acidi carbolici, f?j-*j 4.-8. Gm. 

Glycerini, f£' v *6- Cc. 

Alcoholis, f^iv-vj 16. -24. Cc. 

Aquae destil. , ad 6j ad 480. Cc. M. 

— Duhring. 
Or— 



B . Thymol, . . 
Alcoholis, . 
Aquae destil., 



gr. xv 



1. Gm. 
30. Cc. 
30. Cc. 



M. 



DISEASES OF THE SKIN. 549 

After the disappearance of the acute symptoms more stimulating 
applications are indicated, among which are acidum carbolicum, 
thymol, pix liquida, or oleum cadinum. It is to be remembered, how- 
ever, that the more chronic the affection and the less the inflamma- 
tory symptoms, the more successful is tar in the treatment of eczema. 
I have seen excellent results from resinol ointment in nearly all varie- 
ties of eczema. 

Dr. Duhring considers the following one of the most elegant of the 
tarry ointments : 

H: . Olei cadini, fgiss 6. Cc. 

Cerati simplicis, 3J 30. Gm. 

01. amygdal. amar., gtt. x 0.6 Cc. M. 

Ft. ungt. 

Or— 

R. Picis liquidae, fgj 4. Cc. 

Glycerini, f^j 4. Cc. 

Alcoholis, f5 v j 2 4- Cc. 

Ol. amygdal. amar., gtt. xv I. Cc. M. 

SiG. — To be rubbed firmly into the skin. 

The following is Dr. Bulkley's valuable " liquor picis alkalinus " : 

R. Picis liquidae, ......... f^ij 8. Cc. 

Potassae causticae, gj 4. Gm. 

Aquae destillatae, f 3 v 20. Cc. 

. The potassa to be dissolved in water and gradually added to the tar with 
rubbing in a mortar. 

SiG. — To be used diluted. 

A very elegant preparation of tar is the French mixture known as 
" Goudron de Guyot." 

For eczema rubrum, one of the most intractable varieties of the 
disease, especially the chronic eczema of the legs, the following mode 
of treatment, first suggested by Hebra, is the treatment par excellence. 
The accompanying instructions are to be adhered to. " A lump of 
the sapo viridis (made originally of herring-fat and potassa, and con- 
taining three per cent, of caustic potassa), the size of a small nut, is 
smeared upon a piece of wet flannel and applied to the affected part, 
and firmly rubbed until the soap has disappeared, when the flannel 
is to be dipped into warm water and again applied to the part and 
rubbed until an abundant lather forms, more water being added from 
time to time until the suds are most abundant, when the surface is 



550 PRACTICE OF MEDICINE. 

thoroughly washed and freed from all the soap and carefully dried j 
after which the following (Hebra's diachylon) ointment, having been 
spread before the application of the soap, is to be applied. It is pre- 
pared as follows : 

" Fifteen ounces of the best olive oil are added to two pounds of 
water, and heated to boiling in the water-bath. Three ounces and 
six drachms of an equally good article of litharge (plumbi oxidum) 
are dusted over the fluid in ebullition, which is constantly stirred 
throughout, in order to prevent the formation of fatty acids. During 
the cooking, water is occasionally added as required. The stirring is 
to be continued until the ointment is quite cold. 

" The ointment is spread upon strips of soft muslin and the affected 
part enveloped, care being exercised that neither folds nor wrinkles 
occur, the whole being covered by a firm roller and the patient being 
able to go about as usual. The entire operation is to be repeated 
twice daily." 

A modification of the above ointment, technically known as " un- 
ruentum diachyli albi of Hebra" has been successful in my hands in 
a number of cases. The formula is — 

R . Emplast. plumbi, 

Vaselini, aa ^j aa 30. Gm. 

01. lavandulae, q. s. q. s. M. 

Dissolve with heat and stir till cold. 

Sic. — Apply on strips. 

Prof. Da Costa has used with success, in eczema rubra, liquor 
arsenici et hydrargyri iodidi, rr^ij — v (0.12-0.3 Cc), after meals, and — 

]& . Ung. plumbi subacet., giv 16. Gm. 

Acid, carbolici cryst., ..... gr. iij 0.2 Gm. 

Ung. petrolei, 3 iv 16. Gm. M. 

Sig. — Apply freely on muslin strips. 

An excellent formula for eczema of the vulva is — 

I£ . Iodoformi, gss 2. Gm. 

Bal. Peruviani, ........ f^j 4. Cc. 

Ung. petrolei, 5J 30. Gm. M. 

Sig. — Apply on soft cloths. 



DISEASES OF THE SKIN. 551 

TREATMENT OF SPECIAL FORMS AND VARIETIES OF 
ECZEMA. 

Eczema capitis is either erythematous, vesicular, or pustular in 
character. If the first named, it at once tends to become chronic, 
settling into the variety known as eczema squamosum, often involving 
the entire scalp and accompanied with inte7ise itching. The pustular 
variety is the more common form, occurring upon the scalp of chil- 
dren and young adults, existing as a few patches, or, what is more 
frequent, involving the entire scalp. The pustules soon rupture, the 
liquid drying into greenish-yellow crusts, often covering the whole 
scalp with a cap of crust. The hair becomes matted and caked, the 
sebaceous secretions collect, and if the part is not cleansed, becomes 
offensive. In severe cases of pustular eczema of the scalp enlarge- 
ment of the lymphatic glands of the back of the neck and of those 
behind the ear occur; but they never suppurate. Pediculi are fre- 
quently associated with eczema capitis in children, either as a primary 
cause or a result of the matted condition of the hair constituting a 
favorable habitat for them. 

Eczema capitis may be confounded with psoriasis, seborrhcea, 
syphilis, tinea favosa, and tinea tonsurans. 

Treat7ne?it. If the pustular variety, removal of the crusts is the 
first indication. This is accomplished by saturating the scalp either 
with oleum olives or oleum amygdalce dulcis, and then washing with 
warm water and soap, or the use of a starch poultice or a twenty-five 
per. centum solution of boroglyceridum ; after their removal the ap- 
plication of the following ointment, recommended by Professor Da 
Costa : 

K; . Hydrargyri chlor. mitis, . . . . gr. xx 1. 3 Gm. 

Acid, carbol. cryst. , gr. iij 0.2 Gm. 

Ung. petrolei, gj 30. Gm'. M. 

SiG. — Thoroughly applied. 

The late Prof. Ellerslie Wallace was fond of using the following : 

li . Sodii carbonatis, gr. xxx 2. Gm. 

Ung. petrolei, gj 30. Gm. M. 

SiG. — Apply thoroughly after removal of the crusts. 

I have usually been successful with cleanliness, proper dietary, the 
internal use of liquor arseniciet hydrargyri iodidi , tt\,ss-j (0.03-0.06 Cc), 



552 PRACTICE OF MEDICINE. 

well diluted, after meals, and the local use of acidum boricum, or 
unguenlum zinci oxidum, to which has been added a few drops of 
acidum carbolicum. 

In cases associated vri\h jbediculi I have succeeded with the follow- 
ing, after the removal of the crusts : 

ft . Hydrargyri ammoniat., . . . . gr. x-xx 0.65-1.30111. 

Adeps benzoat. , ^j 30. Gm. M. 

SlG. — Thoroughly applied. 

For the squamous variety of the scalp, the following formula, rec- 
ommended by Dr. Duhring, is excellent: 

ft. Picis liquidse, f^j 4. Cc. 

Glycerini, . fgj 4. Cc. 

Alcoholis, f3 v j 2 4- Cc. 

01. amygdalae amar., gtt. xv I. Cc. M. 

SlG. — Diluted or full strength, rubbed thoroughly into the scalp. 

Eczema faciei. In this location the affection may be either acute 
or chronic. In adults the erythematous variety is frequently encoun- 
tered in patches about the forehead and cheeks. Eczema of the face 
is more common in children, however, the varieties being the vesicu- 
lar and pustular. It is seen on the forehead, nose, and upper lip, and 
is associated with severe itching. 

Treatment. The same as eczema capitis, or the following : 

ft. Zinci oleat., £J 4. Gm. 

Ung. petrolei, ^j 30. Gm. M. 

Eczejna labiorum. Eczema attacks the lips, either alone or in con- 
nection with other parts of the face. One or both lips may be affected. 
The symptoms are, swelling, redness, heat, infiltration, slight scali- 
ness, and fissures. The affection may be in the skin around the 
border of the mouth, or the vermilion and mucous membrane of the 
lips. The mouth may be contracted and the lips partly glued to- 
gether by the exudation and crusts. 

Eczema labiorum may be confounded with herpes labialis and 
syphilis. 

Treatment. Very difficult and discomforting to the patient. 
Among the remedies at times successful are : Argenti nitras, poiassa 
nitras, acidum carbolkum, pix liquida, and collodium flexile. I have 
succeeded in several cases with a powder composed of equal parts of 
acidum boricu?n, acelanilidum, and bismuthum. 



DISEASES OF THE SKIN. 553 

Eczeina palpebrarum. A frequent occurrence in scrofulous chil- 
dren, showing itself along the edges of the eyelids. Pustules involve 
the hair-follicles, followed by the usual crusting. The symptoms are 
swelling, redness, and itching, and unless the parts are frequently 
cleansed, the lids glue together. Conjunctivitis frequently compli- 
cates the affection. 

Treatinent. In mild cases success follows the use of zinci oleatum 
or glyceritum acidi tannici. In severe cases the plan recommended 
by McCall Anderson should be pursued. It consists in the extraction 
of the eyelashes and touching the edges of the lids with a solution of 
poiassa in water, ten grains to the ounce. The edges should be care- 
fully dried and the lid everted, a very small quantity on a delicate 
brush being applied, immediately neutralizing the alkali with acidum 
aceticum or vinegar. 

Eczema barbce. Eczema of the beard is characterized by the forma- 
tion of extensive pustules, showing a preference for about the hairs, 
drying as yellowish or greenish crusts, matting the hairs together and 
adhering to the parts. The affection may be confined to the hairy 
portions of the face, or extend to other regions of the face, be localized 
or general, acute or chronic. 

T? czema barbae in general features somewhat resembles both tinea 

-nd sycosis non-parasitica, but sycosis is an inflammation of 

. follicles only and is rarely associated with crusting, while 

is abundant in eczema. 

tment. Must be energetic and decided. The crusts are to be 

ren^ ed by poultices or warm water and soap. The part to be 

ly shaved ; although quite painful the first time, it is hardly 

ward, and it is to be repeated every two or three days. After 

g, if the attack be acute, the same plan of medication as rec- 

nded by Hebra for eczema rubrum is to be practised, the ap- 

pucciaon to be continuous both day and night, or only at night. If 

the attack be chronic, the following ointment should be applied after 

cleansing and shaving the beard : 

Be. Hydrargyri ammoniat., . . . 
Sulphur, prcecipitati, .... 
Ung. petrolei, ^j 30. Gm. M. 

Slv\ — To be thoroughly applied. 

In this variety of eczema I have seen marked benefit from the use 

47 



". xv-xxx 


r.-2. Gm. 


SS-J 


2.-4. Gm. 


J 


30. Gm. 



554 PRACTICE OF MEDICINE. 

of liquor arsenici et hydrargyri iodidi, n\jj-v (0.13-0.3 Cc), three or 
four times daily. 

Eczema aurium. Eczema of the ears may be either erythematous, 
vesicular, or pustular. If the former, thickening results, with desqua- 
mation of flakes or large scales; if either of. the latter, crusts form, 
which may envelop the whole ear, the symptoms being swelling, red- 
ness, and severe burning and itching, and if the process extend into 
the meatus, occlusion may result, causing temporary deafness. The 
most characteristic symptom of erythematous eczema of the external 
auditory canal, besides the appearance of small flakes, is intense and 
persistent itching. 

Treatment. For acute vesicular or pustular eczema, removal of the 
crusts and the use of hydrargyri chloridum mite as an ointment of 
the strength of thirty grains (two grams) to the ounce (thirty grams). 
If chronic, the use of ftix liquida, as already suggested. For chronic 
erythematous eczema of the external auditory canal, the following 
formula has generally controlled this stubborn condition : 

R. Hydrargyri flav. oxid., gr. j — iij 0.65-0.2 Gm. 

Morphine sulph., gr. j 0.65 Gm. 

Vaselini, ^ij 8. Gm. M. 

Sig. — Apply to the canal. 

Eczema genitalium. This is a most distressing condition. In the 
male the scrotum and penis are involved alone or together, the former 
alone being the more common, and is complicated with eczema of 
the inner side of the thigh or thighs. The symptoms are ; swelling, 
often oedema, moisture, crusts, and painful fissures, followed by ex- 
tensive thickening and accompanied with intense itching. In the 
female the affection attacks the labiae, and, rarely, the vagina and 
mons veneris, and may extend to the surrounding parts, especially to 
the perineum. The symptoms of eczema of the labia are ; great swell- 
ing, oedema, redness, with great heat and a free discharge, forming 
crusts, which are apt to glue the opposing surfaces together. If the 
variety be the erythematous, in place of a discharge with crusts, the 
symptoms named are followed by slight scales. The itching is most 
violent and distressing. 

Treatfnent. The parts attacked should be kept constantly envel- 
oped in cloths wet with a saturated solution of acidum boricum until 
the more pronounced inflammatory symptoms subside, when the 



DISEASES OF THE SKIN. 555 

acidum boricum may be used as a dusting powder, completely en- 
veloping the parts. Mild solutions of menthol are valuable. Tinc- 
twa myrrhce or hamamelis, well diluted, are excellent applications. 
The following is an excellent application for tetter of the scrotum : 

R. Acidi borici, , q. s. for sat. sol. 

Tinct. myrrh., f Jss 16. Cc. 

Tinct. camphone, f ^ ij 60. Cc. 

Hydrarg. chlor. cor., gr. iij 0.2 Gm. 

Aqiue destil., . . . . q. s. adf^viij q. s. ad 240. Cc. M. 

Sig. — Apply several times daily. 

Ointments of zinci oleatum or hydrargyri chloridum mite are some- 
times valuable. Persistent cases will often succumb to the plan of 
treatment suggested by Hebra for eczema rubrum. Resinol ointment 
is often successful. 

Eczema ani. The anus may be attacked alone or associated with 
eczema of the perineum and genitalia. The symptoms are, redness, 
swelling, infiltration, and thickening, with or without fluid exudation. 
Fissures of the anus are usually present, and add to the distress of 
the patient, severe pain attending each stool. Persistent itching and 
burning, worse after retiring, add to the discomfort of the patient. 

Pruritus ani may be mistaken for eczema ani. In the former the 
itching is only associated with such symptoms of inflammation as 
result from the irritation of scratching, while in the latter inflammatory 
symptoms precede the itching. 

Treatment. The more acute symptoms are relieved by bathing the 
parts with a solution of acidum borictim, after which a weak applica- 
tion of acidum carbolicum, either as a lotion or ointment. Resinol 
ointment is invariably curative. The late Prof. S. D. Gross recom- 
mended the application of the following : 

R. Zinci oxidi, £vj 24. Gm. 

Hydrargyri chlor. corrosiv., . . gr. j 0.65 Gm. 

Glycerini, f 3 ij 8. Cc. M. 

Sig. — Apply thoroughly to affected parts. 

Eczema intertrigo. Parts of the body that naturally come into con- 
tact with each other, as about the joints, the inner surfaces of the 
nates, in the groins, and beneath the mammae, are frequently attacked 
with erythematous eczema, which is frequently, but erroneously, 
termed erythema intertrigo, or chafing. The symptoms are, redness, 



556 PRACTICE OF MEDICINE. 

heat, and a moist, macerated surface, aggravated by movement of 
the affected parts. 

Treatment. The application of a solution of acidum boricum, or 
the use of dusting powders, such as zinci oleajum, amy turn, or hydrar- 
gyri chloridum mite. It is essential for successful treatment that the 
opposing surfaces be separated by means of lint or gauze. 

Eczema mammarum. The nipples, and more particularly those of 
primiparae, are at times the seat of a vesicular eczema, with the for- 
mation of crusts and fissures, and unless speedily relieved, develop 
eczema rubrum. The pain on nursing becomes so severe that the 
mother is compelled to refuse the child. It must be borne in mind 
that eczema mammarum occurs in women who are not nursing and 
in single women. 

Treatment. Dr. Tilbury Fox advises the following plan : 

" I. Great cleanliness and care in washing away any remnants of 
milk after each time that the child is put to the breast ; and if the 
nipple be tender and excoriated, use — 

" 2. A little liquor plumbi and calamine powder, as follows : 

R. Liq. plumbi, f^iss 6. Cc. 

Pulv. calaminas prsep., 3 iss 6. Gm. 

Glycerini, f^j 4. Cc. 

Adeps, ^j 30. Gm. M. 

"3. I cover over the nipple with a lead nipple-shield. This excludes 
the air, keeps the part from being chafed, and I think the lead does 
good after the part has become less red and sore. I often use a little 
glyceriiian acidi tannici, painted on night and morning. 

" The above application can always be removed with a little cold 
cream and a little warm-water sponging before the child goes to the 
breast." 

Eczema palmanim et plantarum. The features of the affection in 
both these regions are identical. The diagnosis is often obscured by 
the thickened state of the epidermis. The symptoms are, infiltra- 
tion, thickening, callosity, moisture followed by dryness, and Assuring, 
the last named frequently becoming so deep and painful that the 
patient is unable to use his hands, or, if on the soles, to walk. 

The affection is always chronic, affecting either of the parts alone, 
or all at one and the same time. Itching is a constant and annoying 
symptom. 



DISEASES OF THE SKIN. 557 

The diagnosis is to be made between eczema of these parts and 
psoriasis or' syphilis. 

Treatment. The plan of Hebra for eczema rubrum will usually be 
successful for this variety. The following formula is also valuable : 

R. Hydrargyri oleat., 5-15 per cent., ^iv 16. Gm. 

Olei cadini, f,5 ss 2 - Cc. 

Cerat. simplicis, ^iv 16. Gm. M. 

SiG. — Rub well into part morning and night, first macerating with hot 
water. 

Eczema unguium. The nails are seldom attacked alone, but in 
connection with eczema manuum. The symptoms are roughness, 
want of polish, unevenness, and a punctate or honeycomb appear- 
ance, similar to that seen in psoriasis of the nails. The nail becomes 
depressed, particularly at its root, thus interfering with its nutrition, 
resulting in loss of this appendage. 

Treatment. Internally, arsenicum is a valuable remedy. Locally 
the following : 

R. Ung. picis liq., giv 16. Gm. 

Hydrargyri chlor. mitis, . . . . 3 ss 2. Gm. 

Vaselini, sjiv 16. Gm. M. 

SiG. — Apply thoroughly. 

It is a remarkable clinical fact that very many cases of eczema, 
whether acute, subacute, or chronic, are rapidly cured by the use of 
potassii iodidum in variable doses continued for a long period. 



URTICARIA. 

Synonyms. Hives; nettle-rash. 

Definition. An inflammation of the skin characterized by the 
development of wheals of a whitish, pinkish, or reddish color, accom- 
panied by stinging, pricking, and tingling sensations, often associated 
with febrile and gastric symptoms. 

Causes. Very frequently the result of sudden surface hyperaemia, 
or, rather, too rapid circulation through the superficial capillaries, the 
result of exposure to heat. Irritants and poison produce an attack 
when brought in contact with the skin. Gastric, intestinal, hepatic, 
nephritic, ovarian, uterine, and bladder derangements are very fre- 
quent causes. Certain medicaments ; malaria ; nervous disorders; 



558 PRACTICE OF MEDICINE. 

associated with purpura and rheumatism ; pregnancy ; lactation, 
and the menopause. 

Pathology. An acute inflammation of the papillary layer of the 
skin, characterized by the rapid development, of a " wheal" — a more 
or less firm elevation — consisting of a circumscribed collection of a 
semifluid material, the result of a rapid exudation into the upper 
layers of the skin. The production of the wheal is the immediate 
result of a disturbance of the vasomotor system, which is shown by 
the interference of the circulation in the wheal, the blood being 
driven from its centre to its periphery, causing the whitish apex and 
red areola so characteristic of the developed " hive." 

Symptoms. An attack of "hives " is characterized by the sud- 
den development of wheals upon the cutaneous surface, which usu- 
ally as suddenly disappear, their site being temporarily marked by a 
spot of redness or hyperemia. 

With the appearance of the wheal occur distressing itching, burn- 
ing, tingling, crawling, pricking, a?id stinging sensations, to relieve 
which the patient still further irritates, tears, or otherwise wounds the 
surface by scratching, whence are often developed deep-colored, flat, 
lenticular papules. 

Very frequently an attack of "hives" is associated with fever, 
headache, and gastric disorder. The " wheals " may appear upon 
any portion of the body ; their size varies from that of a pea to that 
of a walnut or an egg — the "giant wheals"; the number varying 
from a very few to being so numerous as to cover the whole 
surface. The shape, size, color, and number of the wheals that 
may occur have given rise to a number of names to designate the 
lesions. Thus, urticaria annularis occurs in rings ; urticaria figurata 
occurs in spirals ; urticaria vesiculosa has a vesicular development 
on the summit of the wheal ; urticaria bullosa, a bullous develop- 
ment at the summit ; ztrticaria papulosa, or lichen urticatus, the 
wheal and a small papule are combined; urticaria tuberosa, or 
giant wheals ; urticaria hemorrhagica, or purpurata urticaria, a 
combination of urticaria and purpura; urticaria evanida, a rapid 
appearance and disappearance of the lesion ; urticaria Persians, 
slow disappearance; urticaria conferta, when the wheals are con- 
fluent; tirticaria pigmentosa, when the wheals are succeeded by 
pigmentations of the site, the tints varying from dark brown, green- 
ish yellow, to a chocolate color ; urticaria febrilis, when the wheals 



DISEASES OF THE SKIN. 559 

are associated with fever ; urticaria ab ingesiis, when associated with 
indigestion. 

Treatment. To prevent the recurrence of the disorder, a thor- 
ough investigation of the cause must be instituted. 

Attention should be directed to the general health, the diet, and 
the secretions. 

The following remedies, alone or variously combined, are often of 
benefit : quinina, pilocarpus, atroftina, tinctura belladonna, a?nmo?iii 
chloridum, arsenicinn, and potassii bromidum. Sodii salicylas, gr. 
iij-v (0.2-0.3 Gm.), every hour or two, followed by a thorough purga- 
tion, often acts like a specific. The following pill is valuable in many 
cases : 

R . Pulv. pilocarpi, 

Ext. guaiaci, aa gr. iss aao.i Gm. 

Lithii benzoat. , gr*. iij 0.2 Gm. M. 

Sig. — Two to four each twenty-four hours. 

If there be atonic dyspepsia and constipation, the following com- 
bination is useful : 

R. Magnesii sulphat., ^j 30. Gm. 

Ferri sulphat. , gr. xvj I. Gm. 

Sodii chloridi, gss 2. Gm, 

Acidi sulphurici dil., fgij 8. Cc. 

Infus. cascarillse, f^i y I2 °- Cc. M. 

Sig. — Tablespoonful before breakfast, diluted. 

Local measures are of the greatest value, either as baths, lotions, or 
dusting powders. The following are among the most serviceable : 
sponging with alcohol, brandy, whiskey, vinegar and water, witch- 
hazel, salt water, alkaline baths, and acid baths. Duhring recom- 
mends the following : 

U. Acidi carbolici, 5 iss 6. Gm. 

Glycerini, fgij 8. Cc. 

Alcoholis, f.^viij 240. Cc. 

Aq. amygdal. amar. , f ^ v i i j 240. Cc. M. 

Sig. — Use as a lotion two or three times daily. 

Bulkley suggests the following : 

K: . Chloralis, 

Camphorae, aa £j aa 4. Gm. 

Misce, and rub and incorporate with 

Pulveris amyli, ,1.HJ 30.-60. Gm. 

Misce, and keep tightly corked in a wide-mouthed bottle. 
Sig. — Rub in with hand. 



560 PRACTICE OF MEDICINE. 

A serviceable formula is the following : 

R • Chloroformi, fgj 4. Cc. 

Ung. zinci oxid., ^ ij 60. Gm. M. 

Sig. — Apply to wheals. 



HERPES. 

Definition. An acute inflammation of the skin, characterized by 
the development of one or more groups of vesicles, filled with a clear 
serum, occurring for the most part about the face {herpes facialis) and 
genitalia (Jierpes proge?iitalis). 

Causes. Herpes facialis ; during the course of febrile and nerv- 
ous disorders ; associated with digestive disorders and colds. 

Herpes proge7iitalis ; the origin is local, from uncleanliness or 
friction. 

Pathology. Hebra defines the various forms of herpes as " a 
series of acute cutaneous diseases of cyclical course, marked by an 
exudation which collects in drops under the epidermis and elevates 
it, forming vesicles which are never solitary, but always appear in 
groups." 

Symptoms. The appearance of the vesicles is usually preceded 
by a feeling of heat in the region, together with slight tumefaction or 
swelling. Rarely the herpetic attack is attended with malaise and 
pyrexia. 

The eruption usually appears in the form of a small cluster of pin- 
head to split-pea sized vesicles, containing a clear fluid, becoming 
cloudy, afterward puriform, and drying in small, yellowish or brownish 
crusts ; they are few in number, and may coalesce. They disappear 
without leaving a scar. 

Herpes facialis ; occur upon any portion of the face, but most fre- 
quently about the lips — herpes labialis. The alse of the nose, auricles, 
and the mucous membranes of the mouth and tongue are frequent 
locations, in the latter appearing as excoriated patches from rupture 
of the vesicles. 

Herpes progenitalis ; in the male the chief site is the prepuce 
(herpes prapidialis). In the female they are comparatively rare ; but 
when occurring, it is upon the labia? majora and minora and the skin 
about the vulva. 



DISEASES OF THE SKIN. 561 

This variety is preceded by burning, itching, or neuralgic pains, 
accompanied by redness, congestion, and more or less oedema. 

The lesion about the genitalia is likely to be mistaken for one form 
or other of venereal disease. 

Herpes gestationis ; a rare affection of the skin occurring during 
pregnancy, consisting of erythema, papules, vesicles, and bullae, at- 
tended with intense burning and itching. It may appear at any time 
of pregnancy up to the seventh month, and continues until some 
time after delivery. 

Treatment. Herpes facialis seldom calls for treatment, although 
in marked cases of herpes labialis protection with liquor gutta-percha 
or collodium flexile promotes desiccation. 

Herpes progenitalis ; cleanliness is of the first importance. Coat- 
ing the eruption with the medicaments mentioned above, or washing 
with a saturated solution of acidum boricum, and afterward dusting 
with hydrargyri chloridum mite, are useful. In recurring cases of 
herpes of the vulva, arsenicum is a specific (Jonathan Hutchinson). 

The parts may be rendered less sensitive in frequently recurring 
cases by astringent lotions, as acidum tannicum or zinci sulphas. 
Circumcision, when required, may be practised. 



HERPES ZOSTER. 

Synonyms. Zono ; shingles ; a girdle ; intercostal neuralgia. 

Definition. An acute, inflammatory disease ; characterized by 
the development of groups of firm and distended vesicles situated 
upon inflamed bases corresponding to a definite nerve trunk, and 
accompanied by more or less severe neuralgic pains. 

Causes. The eruption and consequent neuralgic pains are the 
immediate result of an inflammation of the ganglia or of the nerve 
trunks and branches, — a neuritis, — probably of the trophic fibers of 
the affected part ; but the cause producing this condition is obscure. 
Among the many that have been suggested are : cold, injuries to 
nerves, anaemia, malaria, and the medicinal use of arsenicum. 

Pathology. An inflammation of either the ganglia, the nerve 
trunk, or branches — probably the trophic system — causing the devel- 
opment of vesicles in the lower strata of the rete with " the infiltra- 
tion of serum and inflammatory cells " of the papillae and corium. 
48 



562 PRACTICE OF MEDICINE. 

Symptoms. Begins with neuralgic pains, either of a burning or 
lightning-like character, with slight febrile phenomena, followed by 
the appearance of papulo-vesicles along the tract of pain ; these soon 
become vesicles situated on bright-red, highly inflamed bases. The 
vesicles are about the size of pin-heads, or, perhaps, a little larger ; 
usually discrete, although they frequently coalesce, forming irregular 
patches, coming in groups until the third to the fifth or even tenth 
day, when they gradually desiccate, and at the end of the second 
week nothing remains but a slight scar, which may disappear or 
become permanent. 

When the eruption is at its height, it is perfect in its anatomical 
formation, each vesicle being well shaped and seated on a bright-red, 
inflamed patch of skin, and distended with a translucent, yellowish 
fluid. 

The eruption is almost invariably confined to one side (unilateral) 
of the body, although in rare instances it is seen upon both (bilateral) 
sides. It is usually found upon well-known nerve tracts. According 
to the region affected it is termed zoster capitis, zoster frontalis, zoster 
faciei, zoster ophthalmicus, zoster auricularis, zoster nucha, zoster 
brachialis, zoster pectoralis, zoster abdominalis, zoster fe?no?'alis. 

Diagnosis. The lesions of shingles are usually so well marked 
that an error in diagnosis should not occur. The neuralgic pain 
preceding the eruption and its development in distinct groups upon 
inflamed bases following a nerve tract are so different from the simple 
herpes of the face or genitalia, or from the lesion of eczema. 

Prognosis. Favorable. The affection is self-limited, the dura- 
tion being about two weeks. It is said that " zoster of the orbital 
region may seriously involve the eye and prove fatal." 

Treatment. The affection is self-limited. The indications are to 
relieve the pain and protect the vesicles from irritation. The follow- 
ing combination diminishes the pain and modifies the duration : 

R . Zinci phosphidi, 

Ext. nucis vomicae, aa gr. x aa 0.6 Gm. M. 

Ft. pil. No. xxx. 

Sig. — One every two to four hours. (Bulkley.) 

Prof. Bartholow " has seen excellent results in cases of shingles 
from galvanization of the affected intercostal nerves — the positive 
pole being placed over the point of emergence of the nerves, and the 
negative brushed over the terminal filaments of the skin." 






DISEASES OF THE SKIN. 563 

The general symptoms are to be treated as indicated. Anaemia or 
depression are benefited by full doses of ferri et quinince citras. 

For the pain no remedy seems comparable with the hypodermic 
use of morphincE sulphas, gr. %-% (0.008-0.022 Gm.), with atropines 
sulphas, gr. y^- (0.00065 Gm.), near the lesion. Antipyrin, gr. xv 
(1 Gm.), repeated every three or four hours, or phenacetm, gr. v 
(03 Gm.), every three or four hours, relieves the pain in many cases. 
Sodii salicylas gr. x-xv (0.6-1 Gm.) every few hours is recommended. 

Locally, relief follows coating the " shingles" with either collodium 
flexile or liquor gut la perches, to which morphines sulphas may be 
added. Aristol dusted over the lesions, or acidum boricum, as a pow- 
der, or combined with lanolin, is useful. 



MILIARIA. 

Synonyms. Lichen tropicus ; miliaria rubra ; miliaria alba ; 
prickly heat. 

Definition. An acute inflammation of the sweat glands ; char- 
acterized by the development of discrete, whitish or reddish, pin-point 
and millet-seed-sized papules, vesicles, or vesiculo-papules, productive 
of prickling, tingling, and burning sensations of a most aggravated 
character, associated with more or less malaise. 

Causes. Excessive heat, the result of excessive or tightly-fitting 
clothing, or a high external temperature. Most frequent in fleshy 
adults who perspire freely, and in children. Nervous prostration; 
severe dyspepsia and general debility seem to predispose to "prickly 
heat." 

Varieties. Miliaria papulosa ; miliaria vesiculosa. 

Pathology. The pathology of the two varieties is the same — both 
inflammatory affections of the sweat glands ; in the one papules, in the 
other vesicles, develop about the orifices of the excretory ducts. 

In either variety occurs hyperasmia of the vascular plexus of the 
sweat glands, followed by slight exudation about the ducts, giving 
rise to the minute papules or vesicles, which remain until the cause 
has been modified or removed, when they are rapidly absorbed. 

Symptoms. Miliaria papulosa, known as lichen tropicus and 
" prickly heat," is of sudden onset, with the occurrence of numerous 
minute, acuminated bright-red papules, about the size of a pin-head 



564 PRACTICE OF MEDICINE. 

or millet-seed, and but slightly raised above the level of the skin. 
The papules are preceded by and accompanied with sweating (hyperi- 
drosis) and distressing tingling, pricking, and- burning sensations. 
If the attack be severe, vesico-papules and vesicles are freely inter- 
spersed among the numerous papules. Rarely the secretion of sweat 
is notably diminished. 

Miliaria vesictilosa ; in this variety, instead of papules, immense 
numbers of vesicles develop, of the size of pin-points and pin-heads, 
of a whitish {miliaria alba) or yellowish-white color. The surface 
from which they arise is of a bright-red color, owing to each vesicle 
being surrounded by an areola {miliaria rubra). The vesicles are 
preceded and accompanied with sweating (hyperidrosis) and most 
distressing li?igling, pricking, and burning sensations. 

Either variety may attack all parts of the body, but the abdomen, 
chest, back, neck, and arms are the regions usually invaded. 

Duration. This varies with the cause. It may appear, fully de- 
velop, and disappear in a few hours. In those predisposed it may 
continue more or less marked throughout the entire summer. 

Diagnosis. If the cause, nature, and seat of the affection are 
taken into consideration, no error should occur. 

Eczema papulosum has a resemblance to " prickly heat," but the 
course of eczema is slow, and the papules are larger, more elevated, 
and firmer than those of miliaria papulosa. 

Eczema vesiculosum and miliaria vesiculosa are to be differentiated 
by the marked differences in the progress of each, — the former slow, 
the latter rapid ; the vesicles of the former rupturing spontaneously, 
those of the latter only when severely irritated. 

Sudamen is not an inflammatory affection, while miliaria is. 

Prognosis. The affection is often most rebellious in fleshy per- 
sons and children, and if neglected, it passes into eczema or an 
erythematous intertrigo. 

Treatment. The patient should be kept as cool as possible, and 
avoid undue perspiration. The fears entertained by the laity, of 
danger from retrocession of the eruption, are groundless ; the sooner 
it disappears, the better for the comfort of the patient. 

The food should be light and unstimulating, dispensing with meats 
and condiments for a few days ; wine, spirits, and beer are to be 
avoided. 

The ingestion of water, lemonade, Apollinaris water, Vichy water, 



DISEASES OF THE SKIN. 565 

together with refrigerant diuretics, as potassii ciiras vel acetas, a cool 
apartment, and absolute rest will ordinarily insure speedy relief. 
Saline cathartics are invaluable. 

Locally: sponging with alkaline lotions, liquor plumbi subacetatis 
dilulus, extraction grindelice fluidum well diluted, or a solution of ham- 
amelis, or cupri sulphas in solution (gr. x — 0.6 Gm., aqucs f^j — 30 
Cc), or acidi carbolici (gr. xx — 1.3 Gm.), glyceriti amyli (^iij — 90 
Gm.), or a dusting-powder consisting of lycopodiwn, zinci oxidum, 
and amylum, singly or combined. 



PEMPHIGUS. 

Synonym. Water blisters. 

Definition. An inflammatory disease of the skin, either acute or 
chronic, characterized by the development of a succession of rounded, 
irregular-shaped blebs or bullae, varying in size from a pea to an egg. 

Varieties. Pemphigus vulgaris ; pemphigus foliaceus. 

Causes. Obscure. It is usually associated with a depressed state 
of the general system ; disorders of menstruation ; during preg- 
nancy. 

Pathology. Hebra thus describes the appearance of the blebs : 
"Sometimes a circumscribed, light-red spot appears, perhaps of the 
size of a bean or a large coin ; this is paler in the centre, and may 
even present a tinge of white, indicating the point at which the bleb is 
to form, and from which it will spread outward over the surrounding 
skin, and, in fact, is at first a wheal, passing afterward into a bleb. 
In other cases the bleb is not preceded either by a red spot or by a 
wheal, but begins originally as a small collection of clear fluid beneath 
the cuticle. Thus, hyperaemia of the skin may exist before exudation 
is poured out, or the latter may be formed before any congestion of 
the papillary layer is discoverable." 

The contents of the blebs or bullae are yellowish or colorless serum, 
of a neutral or alkaline reaction; the older the fluid, the more alkaline 
it becomes. In the late stages of a bleb the fluid becomes puriform. 
In rare instances blood is contained in the bleb (pe?nphigus hemor- 
rhagica). 

Symptoms. Pemphigus vulgaris ; the onset is slow {pemphigus 
chronicus), without constitutional symptoms, or acute {pemphigus 



566 PRACTICE OF MEDICINE. 

acutus), preceded by febrile reaction. The lesions are the successive 
development of blebs, usually from half a dozen .to a dozen, varying 
in size from a pea to an egg, of a round or oval shape, their walls 
distended with a colorless fluid, the color becoming yellowish or puri- 
form as they grow older. They develop abruptly from the sound 
skin, with a definite line of demarcation, unattended with symptoms 
of inflammation. A characteristic phenomenon of the lesion is its 
successive appearance ; a crop no sooner disappears than another 
forms, throughout the course of the affection, each crop running its 
course in from three to six or ten days. With the appearance of the 
blebs occur ztehing and burning, usually of a mild character, although 
occasionally in a distressing degree {pemphigus pruriginosus). 

Pemphigus malignus is characterized by the great size and number 
of the blebs, which coalesce, rupture, and are succeeded by excoriated 
surfaces, which occasionally take on ulcerative action, the patient's 
health being seriously impaired. 

Pemphigus foliaceus differs from pemphigus vulgaris in that the 
blebs, instead of being distended or tense, are flaccid and only par- 
tially filled with fluid, as they rupture before arriving at their state of 
full development. This variety also appears and disappears in crops. 
After rupture the fluid immediately dries into thin, whitish flakes, 
which are detached in quantity, leaving a red, excoriated surface — 
the rete and corium. If the affection has continued for some time, 
the skin presents the appearance of a superficial scald. The course 
of this variety is essentially chronic. 

All portions of the body are liable to the lesion, as also the mucous 
membrane of the mouth and vagina. It is most common, however, 
upon the limbs. 

Diagnosis. In a typical case no difficulty should be experienced 
in making a diagnosis. The mere presence of blebs, however, does 
not necessarily constitute pemphigus, for it must be remembered that 
they are at times developed in other diseases, as well as by artificial 
means; the appearance of blebs in crops is a strong diagnostic point. 

Prognosis. The course of the affection is most uncertain, and 
relapses are frequent. In arriving at an opinion the occurrence of 
fatal cases must not be forgotten. 

Treatment. Attention to the general health is of the greatest 
moment. A careful study of the cause should be made, and, if deter- 
mined, means for its removal are of the first importance. 



DISEASES OF THE SKIN. 567 

Two remedies, arsenicum and quini7ia, are of great value, the secret 
of success being the persistent use of the former ; or if the latter be 
used, the dose should be large. 

Local measures are also of importance. The blebs should be 
punctured and evacuated as soon as formed. The use of dusting- 
powders of acidum boricum, zinci oxidum, ci7nylu?n, or violet-powder, 
or lotions of liquor ftlnmbi subacetatis dilntum, are valuable. 

Hebra recommends the continuous bath. 



IMPETIGO. 

Definition. An acute inflammatory disease, characterized by the 
development of one or more discrete, rounded and elevated, firm 
pustules, about the size of a pea, unattended with itching. 

Causes. Occurs for the most part between the ages of three and 
ten years, in the well-nourished and healthy. It is not associated with 
eczema. It is not contagious. 

Pathology. The lesion is a well formed, typical pustule, develop- 
ing abruptly from the surface, containing a whitish-yellow fluid, pus- 
corpuscles, blood-corpuscles, epithelial cells, and cellular detritus. 
The abscess or pustule is about the size of a pea, circumscribed, and 
superficial. 

Symptoms. Begins by the development of from one or two to a 
dozen or more distinct pustules, about the size of a split pea, of a 
rounded shape, raised above the surface, with thick walls, of a yellow- 
ish or whitish color, surrounded by a distinct areola, which soon 
fades, are without a central depression or umbilication, and unat- 
tended by either itching or burning. 

The affection runs an acute course, usually lasting a couple of 
weeks. The pustules, after attaining their full size, remain stationary 
for a few days, when they disappear by absorption and desiccation, 
the crusts dropping off, displaying a reddish base, which soon disap- 
pears without pigmentation or scar. 

The pustules occur on all portions of the body, the most frequent 
locations being the face, hands, fingers, feet, and toes. 

Diagnosis. Impetigo is unassociated with general symptoms, 
and its particular lesion — the pustule — is discrete, — points of impor- 
tance in the diagnosis. 



568 PRACTICE OF MEDICINE. 

Eczema pustulosum is also a pustular affection, but the large num- 
ber, their disposition to coalesce, their location upon an inflammatory 
base, their rupture and subsequent crusting and itching, are diag- 
nostic points. 

The diagnostic points from ecthyma will be pointed out when 
describing that affection. 

Prognosis. Favorable. 

Treatment. The pustules should be opened as soon as they 
mature, the contents removed by washing with tepid bichloride water 
and the floor covered with hydrargyri chloridum mite or zinci oleatum. 

Coating the pustules with collodium flexile or liquor gutla perches, 
if they are located where irritation be liable, is valuable. 



ECTHYMA. 

Definition. An affection of the skin, characterized by the forma- 
tion of one or more large, isolated, flat pustules, situated upon an in- 
flamed base. 

Causes. It is most common among those who live in squalor and 
poverty, and in delicate and poorly-nourished children. Improper 
and insufficient diet, want of ventilation, excessive work, and un- 
cleanliness are all prominent causes. 

Pathology. The lesion is a typical pustular process, severe but 
superficial, and not extending beyond the papillary layer of the 
corium. The pustule is situated upon a firm and highly inflamed 
base ; the number varies from one to a dozen or more. 

Symptoms. The disease is characterized by the development of 
one or more, round or oval, yet flat, pustules, about the size of a pea- 
bean, attended with moderate heat, bur?ii?ig, and pain, and, if the 
number be large, slight febrile reaction. The pustules are first 
yellowish in color, surrounded by a firm and sensitive bright-red 
areola, the pustule afterward becoming reddish from the admixture 
of blood, soon drying into flat crusts of a brownish color. The dura- 
tion of each pustule is between two and three weeks, new ones form- 
ing until the cause is removed. 

The most prominent sites are the thighs, legs, shoulders, and back. 

Diagnosis. Ecthyma and eczema pustulosum have points of 
resemblance, but a study of the clinical history of the latter should 
prevent error. 



DISEASES OF THE SKIN. 569 

Impetigo differs from ecthyma in the size of the pustule and crust. 

Ecthyma differs from a boil in not having a central core. 

Prognosis. With care and the removal of the cause, recovery is 
always prompt. 

Treatment. The general treatment of the patient is of the first 
importance. Nutritious and wholesome food, cleanliness, bathing, 
fresh air, and regulated exercise should be advised, together with such 
tonics ttferrum, arsenicum, quinina, strychnina, and mineral acids. 

Locally : Remove the crusts by first soaking with oil or fat, or water 
dressings, and apply — 

R. Ungt. zinci oxid. benz., , . . . t ^ss 15. Gm. 

Vaselini, ^ ss 15. Gm. 

Hydrargyri ammoniati, £) j 1.3 Gm. M. 

Ft. ungt. (Duhring.) 

Pustules showing a sluggish disposition to heal should be stimulated 
by touching with either argenti nitras or acidum carbolicum. 



FURUNCULUS. 

Synonyms. Furunculosis ; furuncle ; boil. 

Definition. An acute affection of the skin, characterized by the 
occurrence of one or more circumscribed cutaneous or subcutaneous 
abscesses (boils), which usually terminate by necrosis of the central 
tissue, its subsequent expulsion in the form of pus or a core, and a 
resulting cicatrix. 

Causes. The result of a depraved condition of the system, induced 
by general debility, excessive fatigue, nervous depression, improper 
food and exercise, anaemia, diabetes, uraemia, or the result of local 
friction, pressure, or contusions. 

Pathology. The process resulting in a " boil" has its origin in 
either a sebaceous gland, a sweat gland, or a piliary follicle, and never 
begins in the meshes of the corium. " It begins as a small, roundish 
spot which increases in size until certain dimensions are attained, 
when it undergoes suppurative change, resulting in the formation of a 
central point or core, composed of the tissue of the gland in which 
the furuncle originated, which, together with the pus, is cast off. It 
shows no disposition to become diffuse, being always a circumscribed 
inflammation. After the discharge of the core a cavity of more or 
less depth remains, showing the tissues around it to be hard and infil- 



570 PRACTICE OF MEDICINE. 

trated. After a few days or a week it fills up by granulation, leaving 
a cicatrix which i*s often permanent. The central point or core, when 
thrown off, is composed of a whitish, tough, pultaceous mass of dead 
tissue, varying in size with the extent and depth of the inflammation" 
(Duhring). 

Hydro- adenitis, as seen in the axillae, around the nipples, and 
about the anus or perineum, differs from the ordinary " boil" merely 
in being deeper seated. 

Symptoms. " Boils " may occur singly, or more commonly in 
crops of two, three, or more, another crop following their disappear- 
ance (furunculosis). 

The abscess begins as a small, rounded, imperfectly defined, iso- 
lated, reddish spot, of a highly inflamed character y painful on pressure, 
its size gradually increasing, its central point presenting evidences of 
suppuration. It reaches its full development in about a week, when 
it consists of a slightly raised, rounded, and pointed inflammatory 
swelling, with a yellowish point in the centre — the " core." Abscesses 
with no central suppuration or core are called " blind boils." The 
size of a developed boil varies from a split-pea to a walnut, the color 
deep red, with a yellow centre, and is surrounded by a slight areola. 
The pain of a boil is dull and throbbing, painful on pressure, and is 
usually worse at night. The constitutional symptoms are mild or 
severe, according to the number and size of the lesions. 

Any portion of the body may be attacked ; its preference, however, 
is for the face, neck, back, axillae, nipples, buttocks, anus, perineum, 
and labise. 

Diagnosis. The characteristics of furuncle are so marked that 
an error seems impossible. It may be, however, mistaken for car- 
buncle, the differences between which will be pointed out when dis- 
cussing that affection. 

Prognosis. No danger results from occasional boils, but when 
occurring in crops, they impair the general health and are rebellious to 
treatment. 

Treatment. The treatment of a single boil is well expressed in 
the word " time." Warm applications are said to hasten the stage of 
suppuration, and when reached, an incision permits the expulsion of 
the "core," after which the cure soon follows. If the lesion is located 
where friction or pressure is likely, protection by either covering with 
adhesive or soap-plaster, smoothly spread, is ample. 



DISEASES OF THE SKIN. 571 

When, however, successive crops of boils occur (furunculosis), the 
treatment should be both constitutional and local. The general 
health being below par, such tonics as arsenzcum,quinina, and ferrum 
are of value. Calciisulphidum, gr. -£$-\ (0.0065-0.008 Gm.), every two 
or three hours, is valuable in these cases. 

Locally, attempts to abort the process may well claim attention, 
among which are : crucial incisions, to relieve the tension of the cen- 
tral point, will often abate the inflammation and prevent the gan- 
grene ; this little operation is rendered painless by the use of the 
ether spray. Acidum carbolicum, used in five per centum solution, of 
which two to five drops may be injected into the apex of the boil, is 
valuable. Painting the forming boil with argenti nilras or tinctura 
iodi is also recommended. A paste made by adding together equal 
parts of glycerinum and extractum belladonna, will often abort a boil ; 
the same is also claimed for unguentum hydrargyri nitratis. 



CARBUNCULUS. 

Synonyms. Carbuncle ; anthrax. 

Definition. An indurated, more or less circumscribed, dark-red, 
painful, deep-seated inflammation of the skin and subcutaneous con- 
nective tissue, terminating in a slough and the subsequent production 
of a permanent cicatrix. 

Causes. Not positively determined. A deep-seated bruise is a 
supposed cause. Perhaps, as in furuncle, impairment of the general 
health is the important factor. It is generally noted to occur in men 
more frequently than in women. Diabetes mellitus. A " specific " 
cause for anthrax is not an improbable discovery. 

Pathology. Although Billroth regards furuncle and carbuncle 
as differing only in degree, the explanation of Warren, of Boston, 
seems the more probable, he being the first to call the attention of 
histologists " to the existence of small columns of adipose tissue lead- 
ing from the panniculus adiposus up to the roots of the lanugo hairs, 
taking an oblique direction in a line with the erectores pilorum. The 
inflammation resulting in suppuration of the subcutaneous adipose 
tissue must either form an abscess or become diffuse. In phlegmo- 
nous erysipelas the latter condition is observed; but when the inflam- 
mation is in the dermoid texture, the exudates infiltrate the skin and 



572 PRACTICE OF MEDICINE. 

naturally follow the canals occupied by the ' columnse adiposae.' The 
pressure thus exerted upon the whole dermoid tissue cannot fail to 
strangulate the circulation, and thus produce gangrene of the tissue, 
even if the exudate be not poisonous enough to destroy the cells by 
its presence. It can, by this explanation, be easily understood why 
this disease is apt to affect the skin on the nape of the neck and the 
back more than on other parts of the body. At this point the skin 
ii dense, its fibrous element extending deep into the adipose layer, 
which is surrounded by strong bands; hence, the pus confined in 
such a place, seeking the easiest outlet, will travel along these minia- 
ture adipose canals, producing the peculiar appearance pathognomo- 
nic of carbuncle." 

Symptoms. Carbuncle is recognized by its form : commencing 
in the lower layers of the cutaneous tissue, it first resembles a phleg- 
mon, minus its bright redness. At first it is somewhat rounded, 
with a tendency to the production of vesicles on its surface, soon, 
however, becoming firm, circular, and flat, and raised above the 
surrounding parts, spreading through the subcutaneous tissue and 
skin, becoming at times enormously large, and having a dark-red 
or violaceous color. As the disease progresses the pressure of the 
carbuncles results in the softening of the tissues, the skin becoming 
gangrenous, breaking down at numerous points, forming perforations, 
through which centres of suppuration appear in different stages of 
advancement, either as whitish, fibrous plugs, or as cavities, from 
which a yellowish, sanious fluid oozes, the surface of the anthrax 
having a cribriform appearance, perforated like a sieve. The entire 
mass terminates in a slough, which, on being detached, leaves a large, 
open, deep ulcer, with firm, everted edges, granulating slowly, a per- 
manent cicatrix marking the site of the lesion. The development of 
the carbuncle is attended by severe pain, of a deep, throbbing, and 
burning character. 

The constitutional symptoms vary with the size, number, and severity 
of the disease; loss of appetite, coated tongue, general malaise, and 
moderate febrile reaction accompany all cases, to which are added 
those of septicaemia in severe cases. 

The duration is from two to six weeks. Its favorite site is the back 
of the neck, shoulders, back, and buttocks. It is usually single. 

Diagnosis. The disease is distinguished from furuncle by its 
great size, its flat form, its course, the multiple points of suppuration, 



DISEASES OF THE SKIN. 573 

and the character of the slough; also by the pain ; in furuncle, sen- 
sitive and painful to the touch, carbuncle not being particularly 
sensitive. Furuncles generally occur in numbers or in crops ; car- 
buncle is almost always single. 

Prognosis. A guarded opinion should always be given, as death 
is not infrequent from anthrax, especially in elderly people with 
impaired health. The mortality, however, is not so great as the laity 
suppose. 

A great danger is septicaemia, from the action of the poison on the 
blood, or the result of secondary abscesses. 

Treatment. Constitutional and local measures are both of the 
greatest value. Nutritious diet, stimulants, and full doses of such 
remedies as tinctura ferri chloridi, quinines sulphas, arsenicum, and 
ammonii carbonas are beneficial. Good results are reported from 
calcii sulphidum, gr. x /% (0.008 Gm.), every two hours. 

Locally: the crucial incision, so generally practised in former 
years, is seldom performed now, the frequent occurrence of hemor- 
rhages being too debilitating. 

A saturated solution of pure acidum ca?'bolicum injected through the 
several apertures in every direction into the sloughing tissues by the 
aid of a hypodermic syringe is often successful. The pain is severe, 
but short-lived. 

Prof. Agne\v recommends painting collodium cum cantharide 
around the anthrax in the form of a broad zone, the effect of the 
blister being to relieve the tension. Ti?ictura iodi is also used for a 
similar purpose. Hebra advocates cloths wrung out in ice-water, or 
ice bags, in the early stages, changing to warm fomentations as soon 
as suppuration has begun. Dr. Ashhurst has practised with success 
the use of pressure by means of adhesive plaster applied in much the 
same manner as for swollen testicle. Success often follows the 
application of tmguentum hydrargyri nitratis, spread at least one- 
eighth of an inch thick and covered with adhesive plaster, changing 
every twenty-four hours. 

The resulting ulcer, after expulsion of the slough, is to be treated 
on general principles. 



574 PRACTICE OF MEDICINE. 



ACNE. 



Synonyms. Acne vulgaris ; acne disseminata ; varus ; stone- 
pock. 

Definition. An inflammation, usually chronic, of the sebaceous 
glands ; characterized by the development of papules, tubercles, or 
pustules, or by a combination of such lesions, usually in various stages 
of formation, occurring for the most part upon the face. 

Varieties. Acne papulosa ; acne pustulosa ; acne artificialis. 

Causes. Not always understood, as the affection is frequently 
associated with apparently the most robust health. A frequent cause 
is puberty. Among the other causes observed are gastro-intestinal 
disorders, anaemia, chlorosis, uterine disorders, urethral irritation, 
scrofula, and the use of large doses of the bromides and the iodides. 
Acne may exist alone or be associated with comedo or seborrhcea. 

Pathology. An inflammation of the sebaceous gland structure 
and surrounding tissues. There first occurs retention of the sebaceous 
secretion, which is soon followed by hyperaemia and exudation about 
the glands and in the gland wall {acne papulosa), infiltration of the 
connective tissue {acne tubercula), followed by suppuration {acne pus- 
tulosa). If the inflammatory action be severe, destruction of the gland 
with a resulting cicatrix occurs. 

Symptoms. Ac?ie papulosa or acne punctata. This variety is the 
earliest stage of the inflammatory action, and is of short duration, 
soon followed by the development of pus. It is characterized by the 
occurrence of pin-head to pea-sized, flat, more or less pointed papules, 
situated about the sebaceous follicles, lightish in color, with a minute 
central black point, the opening of the sebaceous duct. Pustules are 
not infrequently observed scattered among the papules. The lesion 
is unaccompanied with either local or constitutional symptoms. 
While the forehead is the most frequent seat for this variety, they 
sometimes are seen elsewhere. 

Acne pustulosa. This is the fully developed affection. It is seen 
upon the face, neck, shoulders, and back as pin-head to pea-sized, 
rounded or acuminated pustules, seated upon an infiltrated, reddish 
base of superficial or deep inflammatory product [acne indurata). 
Scattered among the pustules may be seen numerous papules. There 
are no constitutional symptoms, nor is pain present unless the pustule 
be handled. 






DISEASES OF THE SKIN. 575 

Acne artificialis is rather a clinical variety, the result, usually, of 
large doses of the bromides or iodides, the lesion being' identical with 
acne pustulosa. 

Diagnosis. The lesion is so characteristic, the course so chronic, 
and the location so frequently upon the face, that an error seems im- 
possible. 

The resemblance of the papular and pustular syphiloderms must 
not be mistaken for acne. 

Prognosis. Essentially a chronic affection, lasting for a number 
of years; but if persistent treatment be employed, recovery will occur. 

Treatment. To successfully combat an attack of acne, both con- 
stitutional and local measures must be employed. 

Constitntio7ial treatment. The successful treatment of a case of 
acne depends upon a knowledge of the cause and familiarity with the 
constitutional habits of the patient. Disorders of digestion and consti- 
pation should be corrected. If anaemia be present,_/^;7'«w and arseni- 
cum are indicated. Scrofula is an indication for oleum moirhutz and 
ferri iodidum. Uterine disorders, if present, should receive proper 
attention. In young adult males I have seen wonderful improvement 
follow the passage of a fair-sized bougie once or twice weekly. 

Calcii suiphidum, gr. ^<r~\ (0.0065-0.032 Gm.), every two or three 
hours, is valuable in many cases, as is hydrargyri chloridum corro- 
sivum, gr. T ^-^V (0.00065-0.001 1 Gm.), three times daily. A remedy 
highly spoken of by Dr. Bulkley is glyceri?ium in tablespoonful doses 
two or three times daily. Dr. Duhring recommends that it be given 
in combination with ferri et qui?iin<z citras. Professor Bartholow 
has seen excellent results from the use of syrupus liypophosphitum 
coinpositus in acne indurata. 

Local treatment. In acne of not very long duration I have seen 
excellent results from the following plan : Just before retiring, the parts 
affected are to be thoroughly washed with water as hot as can possibly 
be borne, and after the water has partly dried, the parts are to be 
thoroughly covered with sulphur sublimatum, applied by means of a 
powder puff-ball, no rubbing or friction to be employed, and on 
arising in the morning the sulphur is to be washed cff with hot water 
and the face lightly mopped dry, or, what is better, sulphur again 
applied, if the patient is willing to permit it, during the day. 

Dr. Hyde recommends that the contents of the papules and pustules 
be evacuated by means of a needle, rather encouraging slight bleed- 



576 PRACTICE OF MEDICINE. 

ing, after which the parts are to be bathed with water as hot as can be 
tolerated, and, while the part is still wet, it is thoroughly scrubbed 
with lotio saponis viridis, then cleansed with water, carefully dried 
and anointed with a sulphur ointment. 

Professor Bartholow suggested, in a case of acne indurata seen with 
the author, the following successful plan. To dissolve the sebaceous 
matter — 

R . Liquor potassse, f 3 j 4. Cc. 

Aquae destil., f Jj 30. Cc. M. 

SiG. — Applied to the acne spots only. 

After which they were anointed with — 

R. Plumbi nitrat., gr. xv I. Gm. 

Ung. petrolei, ^j 30. Gm. M. 

SiG. — Apply twice daily. 

Dr. Duhring recommends the use of the following, after washing 
the parts with hot water : 

R. Sulphuris prsecip., 3J 4. Gm. 

Glycerini, f^ ss 2 - Cc. 

Adeps benzoat, ^j 30. Gm. 

01. rosae, rt\, iij o. 2 Cc. M. 

Ft. unguentum. 

SiG. — To be thoroughly rubbed into the skin at night. 



ACNE ROSACEA. 

Synonyms. Gutta rosea ; rosacea. 

Definition. A chronic hyperaemia or inflammatory affection of 
the nose and cheeks ; characterized by redness, hypertrophy of the 
skin, and dilatation and enlargement of the blood vessels supplying 
the part, with the development of more or less acne. 

Causes. Not always determined. It occurs in young women 
about puberty who are anaemic, or suffer from a general debility, 
nervous irritability or prostration, dyspepsia, or menstrual irregulari- 
ties. It often appears during the menopause. In young males the 
affection can often be traced to nervous or general debility or dys- 
pepsia. The use of spirituous liquors or of large amounts of condi- 
ments is a frequent cause, as is constant exposure to the weather. It 
is frequently associated with seborrhcea. 






DISEASES OF THE SKIN. 577 

Pathology. There first occurs blood stasis in the vessels of the 
part, producing the undue redness first noticed. As a result of the 
stasis, sooner or later the capillaries are dilated and hypertrophied, 
and following the interrupted circulation inflammation of the sebace- 
ous gland (acne) occurs, with the development of papules and pus- 
tules. This constitutes the typical acne rosacea. The affection may- 
proceed no further, remaining at this point for years, or, rarely, the 
pathology of this stage is exaggerated, the involved tissues all hyper- 
trophying, and the connective tissue undergoing a true hyperplasia, 
causing increased size and abnormal shape of the nose. 

Symptoms. The onset of the affection is slow and insidious, 
characterized at first by more or less diffused redness of the part, the 
color aggravated by water or cold air. If the nose be the part at- 
tacked, it is usually greasy (seborrhceic), and is apt to be cool or even 
cold. This condition may remain for years, but sooner or later the 
evidence of dilatation and hypertrophy of the capillaries is apparent 
by the more decided and permanent redness, and upon close exami- 
nation the enlarged minute cutaneous blood-vessels are seen as deli- 
cate or coarse red lines, running superficially over the skin in an 
irregular and tortuous course. Soon are developed upon the hyper- 
asmic and hypertrophied skin papules (acne papulosa) and pustules 
(acne pustulosa), their number never, however, being very great. 
This co?istitutes true acne rosacea. The disease may remain in this 
state, or, rarely, the cutaneous tissues are greatly hypertrophied, the 
blood-vessels enormously dilated, the glands enlarged, and the con- 
nective tissue undergoes hyperplasia, resulting in permanent, dark- 
red, bulky formations, the shape of the nose being contorted into 
various irregular forms. Duhring reports a case in which the nose 
was the size of the patient's fist (rhinophyma). 

Diagnosis. The characteristics of the disease are so marked, 
consisting of rosacea — the dilated and hypertrophic blood-vessels — 
with papular and pustular acne superadded, that an error can hardly 
occur. 

Lupus vulgaris bears some resemblance to acne rosacea, as it is 
apt to develop about the face, and especially the nose ; but the pap- 
ules, tubercles, and pustules of lupus vulgaris soon ulcerate, followed 
by crusts and cicatrices, which never occur in acne rosacea. 

Lupus erythematosus may be confounded with acne rosacea if it 
occurs upon the end of the nose ; but in the former the skin is harsh 
49 



578 PRACTICE OF MEDICINE. 

and covered with adherent whitish and yellowish scales connected 
with the openings of the sebaceous follicles, which is never the case 
in acne rosacea. 

Frostbite resembles the first stage of acne rosacea, but the history 
of the two conditions soon determines the diagnosis. 

Prognosis. Favorable, if treatment be instituted during the first 
stage. After hypertrophy has occurred but little can be accom- 
plished. 

Treatment. The cause is to be sought for and removed, and the 
general health promoted. The use of all alcoholic drinks to be inter- 
dicted, and only small amounts of tea and coffee are to be allowed. 
In the first stage good results may be obtained from the following 
formula, known as " Kummerfeld's lotion " : 

R. Sulphur, praecipitat. , giv 16. Gm. 

Pulv. camphorse, gr. x 0.6 Gm. 

Pulv. tragacanthae, T^j 1.3 Gm. 

Aquae calcis, f 25 ij 60. Cc. 

Aquae rosae, f^ij 60. Cc. M. 

Sig. — Shake the bottle before using and apply every few hours. 

Or— 

R. . Hydrargyri chlor. corrosiv. , . . gr. ij o. 13 Gm. 

Ung. petrolei, 3J 30. Gm. 

SiG. — Apply thoroughly. 

Or, the following, suggested by G. H. Fox: 

& . Cbrysarobini, £ss 2. Gm. 

Collodii, fgj 30. Cc. 

SiG. — Put a brush through the cork and paint lesions every evening. 

For the second stage stronger applications are usually required. 
The dilated capillaries should be incised with a sharp knife, in the 
hope that adhesive inflammation may close the calibre of the vessels, 
cold water compresses being used to control the bleeding, a few of 
the dilated vessels being thus treated every day or two, until all have 
been incised. Another plan is to paint the affected parts, once or 
twice a week, with a ten- to twenty-grain solution oi ftotassa, following 
its application with an emollient poultice. Electrolysis has also been 
recommended. 

I have had excellent results in two typical cases from a long course 
of the extract of thyroid gland gr. j-ij (0.065-0.13 Gm.). 



DISEASES OF THE SKIN. 579 



PSORIASIS. 



Synonyms. Lepra ; alphos ; psora ; English leprosy. 

Definition. A chronic affection of the skin, characterized by 
reddish, more or less thickened and elevated, dry, inflammatory, and 
somewhat wrinkled patches, variable as to size, shape, and number, 
and covered with abundant whitish or grayish colored, imbricated 
scales. It is not contagious. 

Cause. Not known. The source of the affection is, no doubt, 
limited to the skin itself, as no external or internal factors can produce 
it. It occurs in the robust and in the feeble, and in males and females. 
It usually first appears in early life, and recurs at intervals for years. 

Pathology. " The disease is essentially a hyperplasia of the 
normal constituents of the Malpighian layer (mucous layer). The in- 
crease takes place chiefly in the interpapillary portion of the layer, the 
growth of which downward causes an apparent increase in the size of 
the papillae of the corium, which, however, on closer examination, are 
found not to be enlarged. In the later stages of the disease the more 
superficial blood-vessels of the corium become dilated, a more or less 
considerable emigration of the white blood-corpuscles takes place, and 
the immediate neighborhood of the vessels, together with the connec- 
tive tissue of the corium, becomes the seat of a round-cell infiltration, 
which, with the effusion of serum, separates the connective-tissue 
bundles and fibers into an open meshwork. During the period of 
disappearance of the disease there is a gradual return to the normal 
condition, until the hyperplasia, dilatation of the blood-vessels, and 
cell infiltration has completely disappeared. The hair in psoriasis is 
affected from the beginning of the disease, hyperplasia of the external 
root-sheath, the structure corresponding to the Malpighian layer of the 
epidermis, taking place, with extension of the hyperplastic structure, 
into the surrounding cutis. The sebaceous and sweat glands are not 
at any time affected" (Robinson). 

Symptoms. Psoriasis begins as small, reddish spots, of the size 
of a pin's head, which immediately become covered with scanty or 
abundant whitish or grayish imbricated scales. The spots gradually 
increase in diameter, forming patches of various sizes and shapes. 

If one of the scales be detached by means of the finger-nail, it will 
be found to adhere quite firmly to the skin, and to be about the 



580 PRACTICE OF MEDICINE. 

thickness of a card-board. If the reddish patch thus made bare be 
pinched up between the finger and thumb, and compared with a sim- 
ilar pinch of the healthy skin, its inflammatory thickening will be dis- 
cerned. There is no watery discharge at a?iy time. The skin between 
the patches is perfectly healthy. 

While the anatomical lesions are always identical, the eruption 
assumes such features, in the size and shape of the patches, to give rise 
to special names : 

Psoriasis pimctata. The eruption occurs as small, rounded patches, 
about the size of a pin's head. This is a rare variety, as the lesion 
rapidly increases in size. 

Psoriasis guttata. The eruption occurs in the form and size of 
drops, and when covered with scales gives the skin the appearance 
of having been splashed with mortar. A quite frequent variety. 

Psoriasis nummularis. The eruption resembles variously sized 
coins. This is frequently as large as the patches grow. 

Psoriasis circinata. The eruption about the size of the former 
variety, the centre clearing away, leaving the skin normal, although 
it may continue to enlarge at the periphery, after the manner of tinea 
circinata. 

Psoriasis gyrata. The eruption in wavy lines, of the width of about 
half an inch, resembling circles and semicircles. This variety is a 
continuation of the former, from the joining of the patches of psoriasis 
circinata. 

Psoriasis diffusa. The patches of eruption are large and of irregu- 
lar shape, covering a considerable amount of surface. This variety 
occurs more frequently on the front of the leg and the outer aspect of 
the forearm. 

Psoriasis palmaris et ftlantaris. In these regions the eruption is 
characterized by larger, thicker, and less lustrous scales, and by the 
occurrence of deep and painful fissures, from which exudes either a 
serous or sanguineous fluid. 

Psoriasis unguium. In psoriasis of the nails they become thick- 
ened, opaque, grayish in color, deeply grooved transversely, and 
often pitted, and in rare cases the nails are replaced by a scaly 
incrustation. 

Any portion of the body is liable to be attacked with psoriasis. The 
only discomfort the patient suffers is from the itching, which at times 
is very severe and distressing. 



DISEASES OF THE SKIN. 581 

Diagnosis. A typical attack of psoriasis presents no difficulty in 
diagnosis. There are a few affections, however, which may be con- 
founding in irregular cases. 

Eczema squamosum occurring upon the legs closely resembles 
psoriasis, and if the former has been attended with a very small 
amount of moisture and the latter has been considerably irritated by 
scratching, the diagnosis will be very difficult. 

The papulo-squamous syphiloderm and psoriasis are frequently 
mistaken for each other, the diagnosis at times being extremely 
difficult. 

Tinea circinata and psoriasis circinata resemble each other, but 
the patches of the latter are less inflammatory, red, and infiltrated, 
and the scales more abundant and larger than the former. Tinea 
circinata is usually the result of contagion, and the scales contain a 
fungus. 

Seborrhcea of the scalp and psoriasis of the same region are 
frequently confounded. In the former the scalp is paler, the scales 
are finer, smaller, more generally diffused, of a grayish or yellowish 
color, and greasy, sebaceous character. Psoriasis of the scalp is in 
patches, which are reddish and infiltrated, and there are almost 
always patches of the disease on other parts of the body. 

Prognosis. An attack can easily be removed, but it is always 
apt to return, so that a permanent cure can never be promised. 

Treatment. Constitutional and local measures are both needed 
in the majority of attacks of psoriasis. 

Constitutional treatment. Attention to the general health, remov- 
ing all deleterious influences, such as dyspepsia, constipation, lithia- 
sis, malaria, anaemia, or catarrhs. 

Among the most valuable remedies used in the treatment of psoriasis 
is arse?iicum, given in full doses for a long period. It is to be kept 
in mind, however, that the drug is contraindicated in all acute and 
inflammatory cases. 

Potassii iodidum in full doses, tinctia'a cantharidcs, quinina, 
phosphorus, acidum carbolictim, and pix liquida have all been used 
with variable success, often what has proved successful for one patient 
being useless in another. 

Local treatment. The character of the local measures should de- 
pend upon the duration of the disease, its extent, location, and obsti- 
nacy. 



582 PRACTICE OF MEDICINE. 

The first step is the thorough removal of the scales. This may be 
accomplished by repeated washings with soft soap and water, or 
plain or alkaline baths or medicated washes. 

In the early stage, with highly inflammatory symptoms, soothing 
applications, such as water dressings, or inunctions with oils, of which 
oleum olives rubbed over the patch several times each day is very 
serviceable. 

For chronic cases nothing seems comparable with the following 
formula, suggested by Dr. G. H. Fox : 

R. Chrysarobini, gr. x-xx-^j 0.65-I.3-4 Gm. 

^Etheris et alcoholis, .... ad q. s. q. s. 

Collodii, . f^j 30. Cc. 

SlG. — Rub the chrysarobin with a little alcohol and ether, and add to 
the collodion. 

If a camel's-hair pencil be placed through the cork, this may be 
painted over the affected patch after the removal of the scales, and 
after drying it will not stain the clothing. Care must be exercised 
that the strength be not too great, or dermatitis may result. 

The following formula I have never seen fail : 

R. Chrysarobini, gr. x-xv— xxx 0.6-1—2 Gm. 

Ung. petrolei, ^j 30. Gm. 

SlG. — Apply to each spot twice daily. 

Jamieson recommends the following: 

1£ . Ammonii carbonat., ^ij 8. Gm. 

Adeps lanse hydrosus, . . . . giv 16. Gm. 

Ceratigaleni, ad 3J ad 30. Gm. M. 

SlG. — Apply three limes a day, followed by a warm bath at night 

Dr. Bramwell, of Edinburgh, reports remarkable success in the 
cure of psoriasis by the internal administration of " a quarter of a raw 
thyroid gland, finely minced and concealed in rice-paper, daily," 
"and no application whatever was made locally." I have had 
excellent results in six cases with the dried gland in doses of from 
gr. j-iij (0.065-0.2 Gm.) three times daily. 

Among local remedies recommended are : pix liquida, saponis viri- 
dis, creasotum, sulphur, and acidum carboliaun. 



DISEASES OF THE SKIN. 583 

HYPERTROPHIES OF THE SKIN. 

LENTIGO. 

Synonym. Freckles. 

Definition. A pigmentary deposit of the skin, characterized by 
irregularly shaped, pin-head or pea-sized, yellowish, brownish, or 
blackish spots occurring for the most part about the face and back of 
the hands. 

Cause. In the majority of instances exposure to the sun is the 
exciting cause. 

Pathology. In anatomical structure freckles consist of a circum- 
scribed, increased amount of normal pigment, differing from chloasma 
only in the peculiar form and size of the deposit. 

Symptoms. The number of "freckles " varies from a very few 
to immense numbers. They occur as brownish or yellowish-brown, 
small, roundish, irregular spots, most commonly upon the face and 
hands. Rarely the number is very great, and they give to the skin 
an uncleanly appearance. They are apt to occur at all ages, but 
rarely before the third year. 

They are unattended with itching or other subjective symptoms. 

Prognosis. Usually favorable. Their course, when left to them- 
selves, is chronic, lasting for years or a life-time. They ordinarily 
appear in the summer, fading away as cold weather approaches, to 
return the following summer. 

Treatment. The following application has usually been success- 
ful : 

U . Hydrargyri chlor. corrosiv., . . gr. iij 0.2 Gm. 

Acid, hydrochloiici dil , . . . fgj 4. Cc. 

Alcoholis, f^j 30. Cc. 

Glycerini, f,! ss l S- Cc. 

Aquee rosce, adfjiv ad 120. Cc. M. 

SiG. — Apply at bedtime, and remove with soap and water in the morning. 

CHLOASMA. 

Synonyms. Liver spots ; moth. 

Definition. A pigmentary discoloration of the skin, character- 
ized by variously sized and shaped, more or less defined, smooth 
patches, or of a discoloration, yellowish, brownish, or blackish in color. 



584 PRACTICE OF MEDICINE. 

Cause. The etiology of chloasma depends upon whether the 
pigmentation is idiopathic or symptomatic in its occurrence. 

Idiopathic chloasma results from the irritation of long-continued 
scratching, such as is practised in severe eczema or pediculosis, the 
application of blisters and sinapisms, heat, the direct rays of the sun, 
and various medicinal and chemical substances, such as follows the 
prolonged use of argentum (argyria). 

Symptomatic chloasma occurs in connection with cancer, malaria, 
tuberculosis, disease of the suprarenal capsule (Addison's disease), 
disease of the womb, pregnancy (chloasma uterinum), neurotic dis- 
turbances, dementia, anaemia, and chlorosis. 

Pathology. The affection is an increased deposit of the normal 
pigment having its seat in the mucous layer of the epidermis. The 
deposition of the pigment is the result of a nervous derangement, 
possibly of the trophic system. 

Symptoms. Chloasma is simply a discoloration of the skin, un- 
attended by alteration of the surface. The patches vary in size and 
shape ; they may be as minute as a coin or as large as the hand, or 
much larger, even to a universal discoloration of the entire surface, 
and they may be roundish or irregular in outline. The usual color is 
yellowish, brownish, or muddy, or even blackish {melasma melano- 
derma). 

In Addison s disease, of a typical character, "the coloration is 
brownish, with an olive-greenish or bronze tint, and is general, 
although, as a rule, especially pronounced upon regions having a dis- 
position to normal increase of pigment, as the face, backs of the 
hands, axillae, areolae of the nipples, and the genital organs; the hair, 
also, may become darkened. Gaskoin reports a case, occurring 
in a woman aged forty-five, where the patch, situated on the cheek, 
near the nose, was intensely dark. It had existed nine years. The 
color of the hair had, fifteen years previously, changed from carroty- 
red to black. For additional symptoms see page 203. 

In argyria, or discoloration of the skin resulting from the internal 
use of nitrate of silver, the color is a bluish, bluish-gray, slate, bronze, 
or blackish, varying as to the shade. It occurs over the surface 
generally, but is more pronounced upon parts exposed, as the face 
and hands. 

Chloasma uterinum occurs most frequently between the ages of 
twenty-five and fifty, seldom after the menopause, caused, in the 



DISEASES OF THE SKIN. 585 

greater number of instances, by changes, physiological and patho- 
logical, which, take place in connection with the uterus. It is seen 
in the married and single, although much commoner in the former. 
Pregnancy is the most frequent cause, although also associated with 
either dysmenorrhcea, chlorosis, anaemia, or hysteria. It is seen in 
the mildest degree about the eyelids, especially during the menstrual 
epoch, as a duskiness or swarthiness of the complexion, either lasting 
a few days or being permanent. As usually encountered, however 
chloasma of this variety consists in the presence of one or several 
patches, appearing generally about the forehead orother parts of 
the face, upon the trunk, about the nipples, and upon the abdomen. 
Rarely the entire face is covered with a discoloration, resembling a 
mask. Cases are recorded in which the pigmentary deposit was 
general, resembling Addison's disease. 

Diagnosis. Tinea versicolor and chloasma resemble each other 
in the color of the patches, but otherwise they have nothing in com- 
mon. Tinea versicolor occurs on the trunk, while chloasma occurs 
upon the face and about the nipples, and in cases the result of preg- 
nancy about the umbilicus, except in those comparatively rare 
instances in which the discoloration is diffused. The patches of 
chloasma are smooth, those of tinea versicolor furfuraceous, as can 
readily be demonstrated by gently scraping the discoloration with the 
finger-nail. 

Prognosis. Unless the result of Addison's disease, the prolonged 
use of argentum, tuberculosis, or cancer, favorable. 

Treatment. Chloasma not the result of organic disease or the 
use of argentum is usually removed by either of the following 
formulas : 

R • Hydrargyri chloridi corrosiv. , . gr. viiss 0.5 Gm. 

Zinci sulphat., 3 ss 2. Gm. 

Plumbi acetatis, % ss 2. Gm. 

Aquee, f \ iv 1 20. Cc. M. 

SlG. — Lotion. Apply morning and evening. (Hardy.) 

Or— 

R . Hydrargyri chloridi corrosiv., . gr. vj 0.4 Gm. 

Acidi acetici dil., f 3 ij 8. Cc. 

Boracis, 7} ij 2.6 Gm. 

Aquoe rosoe, . . . . . . f^iv 120. Cc. M. 

Sig. — Lotion. Apply twice daily. (Bulkley.) 
5o 



586 PRACTICE OF MEDICINE. 

Or— 

R . Hydrarg. ammoniat., ^j 4. Gm. 

Bismuthi subnit., ^j 4. Gm. 

Ung. petrolei, Jj 30. Gm. M. 

Sig. — Apply frequently. 

For argyria the first step is the withdrawal of the argentum, and, 
according to Prof. Bartholow, " a persistent and long-continued use 
of potassiiiodidum and sodii hypophosphitis has, in a few fortunate in- 
stances, caused the absorption and excretion of the silver deposits." 
The action of these systemic remedies for the discoloration may be 
aided by baths of the hyposulphites, and by the cautious use of lotions 
containing potassii cyanidum, which possesses a decided solvent 
power over the silver deposits. 



CALLOSITAS. 

Synonyms. Tyloma ; callus ; callosity. 

Definition. Callositas, or tyloma, consists in tfte development of 
a hard or horny, thickened patch of skin, variable in extent, and of 
a grayish, yellowish, or brownish color, and unattended by pain. 
The most frequent location is upon the hands and feet. 

Causes. The result of pressure or friction, as in the case of the 
hands of the mechanic, the effect of his tools; or, if upon the foot, 
the result of ill-fitting shoes or from long marches. Callosities are 
also seen upon the fingers of violin, banjo, and harp players. 

Pathology. A hypertrophy of the horny layer of the skin, the 
corium remaining normal. The cells of the epidermis become so 
closely packed together as often to simulate horn substance. 

Symptoms. Callositas consists in an increase in the thickness of 
the skin of the affected part, presenting a firm, dense, more or less 
circumscribed structure, the extent of hardness varying considerably, 
sometimes being horny. The patch of hardness is generally about 
the size of a coin, roundish in shape, and somewhat elevated above 
the surrounding skin. The color of the patch may be either grayish, 
yellowish, or brownish. 

Callosities are usually upon the palms, fingers, soles, and toes, 
although other parts, if exposed to the cause, may also be the seat. 
At times great pain and discomfort are experienced from the growth. 



DISEASES OF THE SKIN. 587 

Occasionally callosities are complicated by hyperemia, fissure, acute 
inflammation, abscess, erysipelas, and serve readily as foci for such 
cutaneous diseases as eczema and psoriasis. 

Course. Their formation and development is always slow and 
gradual, If the cause be removed, the prognosis is favorable. 

Treatment, If the removal of the callous growth be desirable, 
the part should be repeatedly soaked in warm water, or a poultice 
applied, or warmed oil kept in contact by compresses of flannel, 
which will soften the induration and permit its removal by paring 
or scraping, layer by layer, with a sharp knife. Success has been 
reported from the use of a plaster of india-rubber containing acidum 
salicylicum u Painting with diluted tinctura iodi once daily is often 
serviceable. 



CLAVUS. 

Synonym. Corn. 

Definition. A corn is a small, circumscribed, usually flat, deep- 
seated hypertrophy of the epidermis, having a horny feel, projecting 
slightly from the skin, painful upon pressure, situated for the most 
part about the toes. 

Cause. Continued pressure or friction, usually from ill-fitting or 
tight boots or shoes. 

Pathology. A clavus consists of a circumscribed, excessive 
hypertrophy of the epidermis, of the same character as occurs in 
callosity, and of a central portion — the core. The core extends 
deeply into the tissues, in the shape of an inverted cone, the base 
of the cone being directed outward and appearing upon the surface 
as a roundish elevation, its apex resting upon the papillary layer of 
the corium. The core of a clavus consists of a whitish, opaque, firm, 
tenacious body, composed of epidermic cells, arranged in concentric 
laminae. 

The pain attending the presence of corns results from pressure 
upon the true skin by the hard core, causing irritation of the nerve- 
filaments of the papillae. 

Corns existing between two toes are constantly bathed with the 
moisture of the part, which macerates and softens the formation, 
which thus receives the name of soft corn, in contradistinction to the 
hard corn. 



588 PRACTICE OF MEDICINE. 

Symptoms. Until the growth attains a considerable size no dis- 
comfort, as a rule, is felt. After, however, its depth has reached the 
true skin, pain, of an intermittent character, aggravated by pressure, 
is the chief symptom. 

Corns are often weather sensitive, being unusually painful before, 
during, or after the occurrence of storms, and should, therefore, not 
be confounded with gouty or rheumatic deposits below the skin. 

Treatment. If freedom from these annoying formations be de- 
sired, the use of a properly fitting foot-covering must be practised. 
The pressure which results in the severe pain is limited by the use of 
the ringed protective plasters in common use. 

To remove the corn, soaking with hot water, or a poultice kept in 
contact over night, will soften the part and permit of its ready removal 
with the knife. 

For soft corns, the application of argenti nitras, in solid stick form, 
is highly spoken of, to be used after the growth has been sufficiently 
softened. The following application will usually remove the " corn " : 

R. Acidi salicylici, 3 ISS 6. Gm. 

Ext. cannab. indices, gr. x 0.6 Gm. 

Collodii, f^j 30. Cc. M. 

SiG — Painted over corn at night and scraped off in the morning. 



VERRUCA. 

Synonym. Wart. 

Definition. A wart consists of a circumscribed hypertrophy of 
the papillary layer, with more or less epidermal accumulation, char- 
acterized by the appearance of a hard or soft, rounded, flat, or acumi- 
nated formation, of variable size. 

Varieties. The following varieties have chiefly a descriptive 
value : verruca vulgaris ; verruca plana ; verruca filif or mis ; verruca 
digitaia ; verruca acuminata. 

Cause. Obscure. The various assigned causes are probably in- 
capable of producing the affection. 

Pathology. While the anatomy of warts differs somewhat accord- 
ing to their variety, in all forms there exists as a basis of their forma- 
tion a connective-tissue growth from which the papillary hypertrophy 
takes place. The interior of the growth is supplied by one or more 
vascular loops, from which their vitality is obtained. 






DISEASES OF THE SKIN. 589 

Symptoms. The various forms are so different as to require a 
separate description. 

Verruca vulgaris, or the ordinary wart commonly seen on the 
hands, consists of a small, circumscribed, elevated growth, having a 
broad base seated securely upon the skin. Their consistency is 
either soft or firm, the surface smooth or rough, the color that of the 
surrounding skin, or yellowish, brownish, or even blackish. They 
may develop upon any region of the body, but are most commonly 
seen upon the hands and fingers. 

Verruca plana differs from the vulgaris in being flat and broad in 
form, and but slightly raised above the level of the surrounding skin. 
Their most common location is either on the back or forehead. 

Verruca filiformis assumes the shape of a minute, thin, conical, or 
thread-like formation, about an eighth of an inch in length. The 
most frequent location is the face, eyelids, and neck. 

Vej-ruca digitata consists of a slightly elevated, broad formation, 
about the size of a split pea, and marked by a number of digitations 
coming from its border, giving an appearance, in marked cases, 
resembling a crab. Their most frequent site is upon the scalp. 

Verruca acuminata, known also as the pointed wart, the moist 
wart, the pointed condyloma, cauliflower excrescence, and venereal 
wart, consists of one or more groups of irregularly shaped elevations, 
often so closely packed together as to form a more or less solid mass 
of vegetations (verrucas vegetantes). Their color depends somewhat 
upon the degree of vascularity, varying from a pinkish, bright red to 
a purple color. They occur, for the most part, about the genitalia of 
either sex. Upon the penis, they usually spring from the glans and the 
inner surface of the prepuce. From the inner surface of the labia and 
from the vagina in the female. They are also seen about the anus, 
mouth, axillae, umbilicus, and toes. They may be either moist or dry, 
according to their location. About the genitalia, a yellowish, puriform 
secretion usually covers their surface, due to friction and maceration, 
which, owing to the heat of the parts, rapidly decomposes, producing 
a highly offensive, penetrating, and disgusting odor. Their size varies 
from that of a pea to that of an almond, an egg, or even the fist. 
Their development is rapid, attaining considerable size in a few 
weeks. 

Prognosis. Favorable. 

Treatment. For the smaller warts, excision by means of the 



590 PRACTICE OF MEDICINE. 

knife or scissors affords the most satisfactory results. If the growth 
be large, and likely to be attended with considerable hemorrhage, 
as in cases of condyloma about the genitalia, the galvano-caustic 
wire or the Paquelin cautery are to be preferred. Transfixing the 
growth in several directions with long needles dipped in a fifty per 
centum solution of acidum chrotnicum has been recommended. The 
topical application of caustics, such as acidum aceticum, acidum 
nitricum, argenti nitras, or ferri fierchloridum is often satisfactory. 
I have been successful in some cases by painting the growth with 
tinctura thuja occidentalis until their size was considerably reduced, 
and then snipping them off with the scissors. The following formula 
for warts and corns is usually successful : 

R . Acidi salicylici, 3 ss 2. Gm. 

Ext. cannab. indicae, gr. v-x 0.3-0.6 Gm. 

Collodii, fI s H 15.-30. Cc. M. 

Sic — Apply once or twice daily. 

An excellent formula is — 

R • Acidi salicylici, 

Acidi borici, aa gr. xv aa I. Gm. 

Hydrargyri chlor. miti*, . . . . gr. x 0.6 Gm. M. 

Sig. — Sprinkle over twice daily. 



ICHTHYOSIS. 

Synonyms. Ichthyosis vera ; fish-skin disease. 

Definition. Ichthyosis is a congenital, chronic deformity or 
hypertrophic disease of the skin, characterized by dryness, harshness, 
or general scaliness of the skin, or in the outgrowth of larger masses 
of a corneous consistency. 

Varieties. Ichthyosis simplex ; ichthyosis hystrix. 

Cause. Often hereditary, but not in all cases. It is to be re- 
garded as an affection which is born with the individual, although it 
does not usually manifest itself until after the first or second year of 
life. 

Pathology. " The diseased or, better, deformed skin is found 
microscopically to be hypertrophied in various degrees, according to 
the development of the malady ; the proliferation of its elements 
occurring in the connective tissue, papillae, stratum corneum, and 



DISEASES OF THE SKIN. 591 

blood-vessels. In well-marked cases of ichthyosis hystrix the 
elongated papillae are surrounded by dense cones of the horny layer 
of the epidermis, more or less concentrically disposed, with sclerosis 
of the connective tissue and a relatively unchanged rete. In this last 
particular the dense plaque of ichthyosis differs in texture from the 
wart " (Hyde). 

Symptoms. Ichthyosis displays wide variation in its symp- 
toms. In one individual it amounts to slight inconvenience, while 
in another it may manifest itself in so pronounced a manner as 
to be the source of great discomfort and deformity. The two varieties 
named represent merely accentuated types of the disorder, rare in its 
fullest development, and, in its slightest, much more common than is 
generally believed. 

A simple dryness and harshness of the skin, with only slight fur- 
furaceous exfoliation, is termed xeroder?na. 

Ichthyosis simplex is the more common variety, consisting of a 
harsh, dry condition of the whole surface, accompanied by the pro- 
duction of variously sized and shaped reticulated scales, either small, 
thin, and furfuraceous, like bran, or large and thick, resembling fish- 
scales. Upon the extremities the scales usually form diamond-shaped 
or polygonal plates, separated from one another by furrows or lines 
which extend down to the normal skin. In color the scales are either 
whitish, grayish, or yellowish, and often have a silvery or glistening 
appearance. Rarely the color is olive-green or blackish {ichthyosis 
nigricans). The amount of scaling depends upon the age of the 
patient and the duration a"nd severity of the disease. 

Ichthyosis hystrix. With or without the development of the above 
variety, in this, the hypertrophy of the skin may occur in circum- 
scribed patches or large areas, consisting of irregularly shaped ver- 
rucous, corneous, corrugated, wrinkled, or rugous masses, usually 
darker in color than those of the simple variety. They may occur 
upon the arms, as solid, warty patches, or upon the back, in the form 
of elongated, linear patches. They may constitute roughened, corru- 
gated, papillary growths, or uneven, horny, blunt, or pointed, spinous, 
warty formations. In the latter case the elevations may reach several 
lines or more, and stand out from the skin like quills upon the back 
of a porcupine — hence the name hystrix. The amount and extent of 
the hypertrophy varies ; the older the patient, the more highly devel- 
oped it will usually be. 



592 PRACTICE OF MEDICINE. 

Course. Ichthyosis simplex may involve the entire surface uni- 
formly or appear more marked on the extremities, from the hips to 
the ankles and the arms and forearms. The affection is always 
worse in winter than in summer, the increased activity of the sweat 
glands at this season producing the most beneficial results. The 
course of the affection is essentially chronic, continuing throughout 
life, now better, now worse. Slight itching usually occurs. 

Diagnosis. The characteristics of the affection are so peculiar 
that an error in diagnosis is hardly possible. It is to be distinguished 
from the inflammatory affections of the skin which terminate in des- 
quamation by the absence of any history of inflammation. 

Prognosis. While much can be done to alleviate the affection, 
the prognosis is unfavorable as regards permanent relief. 

Treatment. Local measures are alone of value for ichthyosis. 
The maceration of the accumulated masses of epithelial hypertrophy 
is accomplished by water-baths, either simple or medicated. The 
relief thus afforded the patient, while temporary, is comforting. 
Duhring says : " It may be stated, then, that, as a rule, the more fre- 
quently the ichthyotic patient bathes, and the longer he is able to 
remain in the water, the less will the deformity show itself." Vapor 
and alkaline baths are also serviceable. Another valuable agent is 
safto mollis in conjunction with baths, or alone, as a discutient. For 
severe cases, " a sufficient quantity is to be rubbed into the skin twice 
daily for four or six days, during which period the patient is to refrain 
from bathing. A bath is first to be taken four or five days after the 
last rubbing, when, in fact, the epidermis has begun to peel off; after- 
ward inunction with a simple ointment is to be applied, in order to 
prevent Assuring of the new skin. 

The following is a useful formula : 

r£ . Adepsbenzoat, 5J 30. Gm. 

Glycerini, lr^xl 2.6 Cc. 

Ung. petrolei, ^ ss 15. Gm. M. 

SlG. — Apply daily, after washing or bathing. 

Or— 

I£ . Potassii iodidi, gr. xx 1.3 Gra. 

Olei bubuli, fjss 15. Cc. 

Adeps, ^ss 15. Gm. 

Glycerini, f^ij 8. Cc. M. 

SlG. — Apply after bathing. (Milton.) 






DISEASES OF THE SKIN. 593 



PARASITIC DISEASES OF THE SKIN. 

TINEA FAVOSA. 

Synonyms. Favus ; porrigo favosa ; honeycombed ringworm ; 
crusted ringworm. 

Definition. A contagious affection of the skin, due to a vegetable 
parasite — Achorion Schonleinii ; characterized by the development of 
either discrete or confluent, small, circular, cup-shaped, pale-yellow, 
friable crusts, usually perforated by hairs. 

Cause. The presence and growth of a vegetable parasite known 
as the Achorion Schonleinii is the cause of tinea favosa. It is com- 
moner in children than in adults, attacking the former in the first 
place either de novo or through direct contagion, and is from them 
communicated to adults. It is a disease confined almost exclusively 
to the lower classes. 

Pathology. Tinea favosa may have its seat either in the hair- 
follicles and hair, or upon the surface of the skin or the nails ; the 
former, however, are the structures most frequently involved. 

It is purely a local affection, due solely to the presence and growth 
of the vegetable parasite discovered by Schonlein, of Berlin, in 1839, 
and named after him — Achorion Schonleinii. The crusts are made 
up almost entirely of fungus, which is seen, upon section, with the 
naked eye, to be composed of a porous mass and to possess a pale- 
yellow or whitish color. ■ Under the microscope it is seen to consist of 
both mycelium and spores in great quantity and in all stages of 
development. 

Symptoms. When the affection attacks the hairs and follicles it 
is termed tinea favosa pilaris ; when the epidermis, tinea favosa epi- 
dermis ; and when the nails, tinea favosa unguium. Rarely all the 
structures may be attacked at one and the same time ; its usual seat, 
however, is the scalp. 

The disease begins by the development of one or of several pin- 
head-sized, pale-yellow crusts, seated about the hair-follicles. In 
about a fortnight these crusts have increased in size and are umbili- 
cated, termed the favus cups, are circumscribed, circular in form, and 
very slightly elevated above the level of the skin. 

In their normal condition they are of a pale-yellow or sulphur- 



594 PRACTICE OF MEDICINE. 

yellow color, but after a time, from dust and other matters, they 
become brownish or greenish yellow in color. The number of crusts 
vary from very few to immense numbers. The usual size is about 
that of a split pea. In tinea favosa pilaris et capitis the affection is 
often accompanied by pediculi, while swelling of the glands of the 
neck and small abscesses upon the scalp are not uncommon. The 
hairs become lustreless, opaque, brittle, and at times split longitudi- 
nally, and from atrophy of the follicles and sebaceous glands perma- 
nent baldness may result. 

In tinea favosa unguium the nails become thickened, yellow, 
opaque, and brittle. 

The disease has a peculiar odor, resembling that of mice, or of 
musty, stale straw. 

Diagnosis. In a recent case of characteristic favus cups, the 
pale-yellow color, the odor, and the history of contagion should ren- 
der the diagnosis easy. If of long standing, however, and the favi 
destroyed by scratching, some doubt may exist; but if a small frag- 
ment of a crust be placed upon a glass slide with a drop of liquor 
polassce, covered with a thin glass, and placed under a microscope with 
a power of from two hundred and fifty to five hundred diameters, the 
features of the Achorion Schonleinii will determine the diagnosis. 

Prognosis. Tinea favosa of the epidermis readily responds to 
treatment. Tinea favosa pilaris is more obstinate, and if of long 
duration, may result in baldness. 

Treatment. The general health, in the majority of instances, 
requires tonics. Oleu?n morrhucs, and syrupus ferri iodidum, are 
invaluable to scrofulous patients. Cleanliness is essential to success- 
ful management. 

For tinea favosa pilaris et capitis two remedies are essential — 
parasiticides and depilation. The hair should be cut off as short as 
possible, the crusts removed by the use of oil, or soap and hot water, 
or poultices, again well oiled, and the hairs removed by means of 
broad-bladed forceps, a few hairs being removed at a time and only 
a small surface cleared at each sitting, when the following lotion is to 
be thoroughly applied : 

1£ . Hydrarg. chlorid. corrosiv., . . . gr. v-x 0.3-0.6 Gm, 

Ammonii chlorid., 3 ss 2. Gm. 

Mistura.' amygdalae amar., . . . . fjiv 120. Cc. M. 
Sic. — Apply thoroughly. (Hulkley.) 






DISEASES OF THE SKIN. 595 

Dr. Shoemaker condemns epilation as injurious to the " hair-folli- 
cles and painful to the patient, and should be discarded as a relic of 
medical barbarism of the last century." He recommends " the appli- 
cation of oleum, ergotce, for twenty-four hours, to soften the crusts; then 
apply a twenty-five to a fifty per centum solution of boroglyceridum, 
sponged thoroughly over the affected surface covered with the oil ; in 
a few hours the crusts will peel off and the surface can be cleansed, 
when the following powerful antiparasitics should be applied " : 

R. Ung. hydrargyrioleat., . . . . % ss 15. Gm. 

Adeps, ^ ss 15. Gm. 

SlG. — Apply a small portion to each cup daily for two or three days. 

Then alternate with the following : 

R. Cupri oleat. , ^ss 2. Gm. 

Adeps, ^j 30. Gm. 

Sig. — Small portion to the affected spots. 

"These applications should be made every day or two, and con- 
tinued for three or four weeks. If, after a cessation of treatment for 
a week or two, the hair does not assume its natural aspect and new 
favus crusts develop, the treatment should be begun afresh." 



TINEA CIRCINATA. 

Synonyms. Tinea trichophytina corporis; herpes circinatus ; 
ringworm of the body. 

Definition. A contagious, parasitic affection of the skin, due to 
the trichophyton fungus ; characterized by the development of one 
or more circular or irregularly shaped, variously sized, inflammatory, 
slightly vesicular or squamous patches, occurring upon the general 
surface of the body. 

Causes. Ringworm of the body is caused by the presence of a 
vegetable parasite discovered by Bazin, in 1854, termed the tricho- 
phyton, the same growth or fungus that produces tinea tonsurans and 
tinea sycosis. The affection is highly contagious, and is frequently 
communicated from one member of a family to another, although it 
has been determined that a certain unknown condition of the skin is 
requisite for its development. In children it is most frequently seen 
among the weakly and the poorly nourished. In adults it is usually 
associated with a decline in the general health. 



596 PRACTICE OF MEDICINE. 

Pathology. The fungus is seated between the strata of the epi- 
dermis, more particularly in the superior layers of the rete. The 
presence of this foreign body produces the subsequent phenomena — 
a superficial dermatitis, erythema, exudation, minute vesiculation and 
papulation, and, in the severe grades, tubercles and pustules. The 
desquamative symptoms are exfoliative — nature's efforts for relief. 

Symptoms. Tinea circinata varies greatly in the degree of its 
development, from the trivial complaint so often seen in children, to 
the chronic, extensive, and obstinate disease sometimes seen about 
the thighs in adults {tinea circi7iata cruris). 

The disease usually begins as a small, reddish, scaly, rounded or 
irregularly shaped spot of papules, which in a very few days assumes 
a circular form (ringworm). It continues to increase in size, the 
papules often changing to vesicles. A characteristic of the eruption 
is its healing in the centre as it spreads on the periphery. Occasion- 
ally the circles or rings coalesce, forming serpiginous lesions. The 
usual size of a fully developed ringworm is about that of a silver 
quarter of a dollar. 

Chronic tinea circinata does not present the characteristic annular 
form, but " are usually in the form of single or multiple, disseminated, 
small, reddish, slightly scaly, ill-defined spots, on a level with or but 
slightly raised above the surrounding skin. Not infrequently they 
are the size of a small or large finger-nail, and are irregularly shaped, 
and, as a rule, without line of demarcation." 

The "eczema marginatum" of Hebra is to be looked upon as a 
severe form of tinea circinata. 

Tinea circinata cruris, or ringworm of the thighs, a variety of the 
"eczema marginatum" of Hebra, is usually complicated with true 
eczema, and is a very obstinate, chronic form of the affection ; it is 
accompanied by severe itching. 

Tinea trichophytina unguium is a rare variety. The nails become 
opaque, whitish, thickened, and soft and brittle, especially along 
their free border. The microscope is essential for a diagnosis. Its 
course is chronic, and it is difficult to cure. 

Course. As commonly seen, ringworm is very amenable to treat- 
ment. Occasionally, however, it exhibits great obstinacy, showing 
itself repeatedly in the same region in the form of relapses, or mani- 
festing itself from time to time in new localities. 

Diagnosis. Tinea circinata may be mistaken for squamous or 






DISEASES OF THE SKIN. 597 

other varieties of eczema, but the circular and often annular form, 
the well-defined margin, the slight desquamation, and the course and 
history of ringworm should prevent error. Chronic ringworm is more 
difficult, however. 

Seborrhcea and psoriasis often assume a somewhat circular form, 
and then have a resemblance to ringworm, but a study of the clini- 
cal history should render the diagnosis easy. 

All doubtful points in diagnosis should be determined by the micro- 
scope. The examination can readily be made in the following man- 
ner : "A few of the scales may be scraped, with a blunt knife-blade, 
from the suspected patch and placed upon a glass slide containing a 
drop of liquor potassae, over which is laid a thin glass cover. The 
cover should be pressed down and the epidermic mass flattened out. 
Permitting the specimen to remain for a few minutes, it may be viewed 
with a power of from 250 to 500 diameters. The fungus will, in most 
cases, be detected here and there, having at first a faint outline, but 
becoming more distinct as the specimen stands." 

Prognosis. Favorable, as a rule, although the affection is rebel- 
lious to treatment in some instances, and prone to relapses. 

Treatment. Local treatment is usually all that is required for 
the cure of tinea circinata. In the majority of instances the following 
plan will be successful. Washing the patch with soft soap and water 
and the application of one of the following ointments: 

U . Cupri acetat., gr. x 0.6 Gm. 

Ung. aquae rosae, ^j 30. Gm. M. 

SiG. — Keep in contact with the patch. 

Or— 

R. Hydrargyri ammoniat., . . . . gr. xx-xxx 1.3-2. Gm. 

Ung. petrolei, ^j 30. Gm. M. 

Sig. — Keep in contact with the patch. 
Or— 

li . Hydrargyri chloridi cor. , ... gr. j 0.065 Gm. 

Tinct. benzoin, comp., .... f^j 30. Cc. M. 

SiG. — Apply over eruption. 
Or— 

1£ . Sulphuris, £j 4. Gm. 

Acid, borici, 3J 4. Gm. 

Yaselini, ^j 30. Cm. M. 

SiG. — Apply after scrubbing patch with green soap. 



598 PRACTICE OF MEDICINE. 

In obstinate tinea circinata cruris a saturated solution of acidum 
boricu?n, applied for a few days, and afterward cover the parts with 
the acid in powder, or unguentum hydrargyi'i ammoniatum. 



TINEA TONSURANS. 

Synonyms. Tinea trichophytina capitis ; herpes tonsurans ; ring- 
worm of the scalp. 

Definition. A contagious, parasitic affection of the scalp, due to 
the trie hop hy ton fungus ; characterized by the development of circum- 
scribed, vesicular or squamous, more or less bald patches, showing 
the hair to be diseased and usually broken off close to the scalp. 

Cause. The result of the presence and growth of the same fungus 
giving rise to tinea circinata — trichophyton. It is an affection of child- 
hood, seldom being seen after puberty. It is highly contagious, and 
may be communicated from a case of ringworm of the body. 

Pathology. The parasite, originally named " trichophyton tonsu- 
rans,''' invades the hair, hair-follicles, and epidermis of the scalp, the 
hair, however, suffering the most severely, becoming in a short time 
filled with the growth to such an extent, usually, as to cause its disin- 
tegration and destruction. The hair-follicle, also, becomes distended 
and prominently raised. The hair-shaft is fractured just above the 
level of the scalp, and usually presents a jagged, bristly, stubble-like 
extremity. The epidermis of the scalp may either present the changes 
of minute vesicles and desquamation, or, in severe cases, cedema 
and inflammatory symptoms, with fluid exudation {tinea kerion). 

Symptoms. Ringworm of the scalp usually begins in the form 
of small circumscribed patches, which soon become the seat of small 
vesicles or pustules, which terminate in desquamation, or of furfur- 
aceous scales. The patches spread rapidly, soon reaching the size of 
a silver quarter to that of a silver dollar. They are circular in form, 
circumscribed, of a reddish, grayish, or greenish-yellow color, covered 
with fine or coarse scales, with the hairs broken off close to the scalp. 
The epidermis of the scalp is more or less raised, and the follicles 
are prominent, giving the characteristic appearance of the disease — 
the goose-skin or plucked-fowl appearance. As a result of the loss 
of hair, baldness, more or less complete, but temporary, exists. 

Itching, slight or severe, is a constant symptom. 



DISEASES OF THE SKIN. 599 

Ringworm of the face or body {tinea circinatd) may complicate 
tinea tonsurans. 

Chronic ringworm of the scalp is the same condition in a more 
chronic form, having existed for six months to a year or two. 

Tinea kerion is a severe variety of tinea tonsurans, " characterized 
by oedema, inflammation, and the exudation of a viscid, glutinous, 
yellowish secretion from the opening of the hair-follicles. When 
fully developed the patches are yellowish, reddish, or purple in color, 
and are more or less raised, cedematous, and boggy. They are uneven 
and honeycomb-like (hence the name kerion), and studded with 
yellowish, suppurative points, or, later, with small cavities or foramina, 
the openings of the distended hair-follicles deprived of their hairs, 
which discharge a mucoid, gummy, honey-like fluid." 

The patches are tender, painful, and at times the seat of itching. 
The course of the affection is chronic. 

Diagnosis. The diagnosis is usually unattended with difficulty, 
if the characteristic circumscribed vesicular or scaly patches with 
stubby hair be present. 

Squamous eczema somewhat resembles tinea tonsurans, but the 
hairs are normal in eczema and firmly imbedded in the follicles, 
while they are almost always stumpy in ringworm, and in those cases 
in which they are not broken off, if pulled, they easily fall out. Ring- 
worm is contagious, eczema is not. 

Alopecia areata presents a white, shiny, ivory-like, bald patch, de- 
void of scales, eruption, or hair. Ringworm has the vesicular or scaly 
patch, with broken-off hairs. 

In any case of doubt the microscope will readily determine the 
diagnosis, if" one or two of the short, stumpy hairs should be placed 
upon a slide with a drop of liquor potasses and permitted to stand a 
few minutes, when under a power of two hundred and fifty diameters 
the fungus, as well as the lesions of the hair, will be visible." 

Prognosis. Favorable, although obstinate in chronic cases. Re- 
lapses are of frequent occurrence. 

Treatment. Local measures are usually satisfactory. Mild cases 
should be treated by cutting the hair as close as possible and thor- 
oughly scrubbing the patches with sapo viridis and water, or the ap- 
plication twice daily of a twenty-five to a fifty per centum solution of 
boroglyceridum, or a six per centum solution of oleatum hydrargyri, or 
either of the following; : 



600 PRACTICE OF MEDICINE. 

&. Sodii borat. , %) 4. Gm. 

Aceti destil., fgij 60. Cc. M. 

SiG. — Apply thoroughly several times daily. 

Or— 

R. Acidi borici, . gr. xv I. Gm. 

Sulphur, flor. , gr. xv 1. Gm. 

Vaselini, ^iss 45. Gm. M. 

SiG. — Apply morning and night. 

Or— 

&. Cupri oleat., . . gss 2. Gm. 

Ung. petrolei, 5 ij 60. Gm. M. 

SiG. — Apply after using boric solution. 

Or use may be made of Morris' thymol solution, to wit : 

$ . Thymol gss 2. Gm. 

Chloroformi, f^ij 8. Cc. 

01. olivae, f 3 vj 24. Cc. M. 

A preparation very popular in London, known as Coster's paste, is 
used by painting the patches with a brush and allowing it to remain 
on until the crust is cast off, in the course of five or six days, when 
it may be reapplied. A few applications often suffice. Its formula is — 

R. Iodi, £ij 8. Gm. 

Olei picis, f 3 j 30. Cc. M. 

The iodine and oil of tar should be gradually and slowly mixed. 

An excellent application in rebellious cases is — 

U . Potassoe (caustic), gr. ix 0.6 Gm. 

Acid, carbolici, gr. xxiv 1.5 Gm. 

Adeps lanre hydrosus, . . . . 3 ss 15. Gm. 

01. theobromre, f^ss 15. Cc. M. 

SiG. — A small amount rubbed into head night and morning. If the scalp 
is not shaved, the application is retained better. 

The following is an excellent application for the scalp in tinea ton- 
surans and other scalp diseases : 

l£ . Ung. acid, borici, % ij 60. Gm. 

Ung. eucalyptol, 3 ij 60. Gm. 

Ol. caryophylli, f3 ss 2 - Cc. 

Glycerini, q. S. q. s. M. 

Ft. unguentum. 

Cases which resist these means are to be treated by removing the 



DISEASES OF THE SKIN. 601 

loose hairs about the edges of the patches and the broken-off hairs 
over the surface by means of small, broad-bladed, short forceps, a 
few hairs only being seized at a time, a portion of the diseased hairs 
to be removed each day until the surface has been cleared. After 
each depilation one of the above formulae to be applied. 



TINEA SYCOSIS. 

Synonyms. Tinea trichophytina barbae ; sycosis parasitica ; 
barbers' itch ; ringworm of the beard. 

Definition. A contagious, parasitic affection of the hair, hair- 
follicles, and subcutaneous tissues of the hairy portion of the face and 
neck in the adult male, due to the trichophyton fungus ; character- 
ized by the development of tubercles and pustules. 

Causes. Tinea sycosis is the result of the presence and growth of 
the same vegetable parasite that causes tinea circinata and tinea ton- 
surans — trichophyton — which invades the hair-follicle and hair. It 
is highly contagious, and is said to be acquired, in most cases, at the 
hands of the barber (?). It is not a very common affection. Like 
the other vegetable growths, it seems to require some peculiar, un- 
known condition of the skin for its development. It may develop 
from a case of tinea circinata or develop simultaneously with it. 

Pathology. The parasite finds its way into the hair-follicles and 
attacks the root and shaft of the hair, causing inflammation, followed 
by more or less follicular suppuration and general infiltration of the 
surrounding tissues. The irritation caused by the presence of the 
fungus results in inflammation of the subcutaneous connective tissue 
and the well-known tubercular formations peculiar to the affection. 
They are firm, comparatively painless, and manifest but little dispo- 
sition to undergo change, remaining during the presence of the fungus 
and finally gradually disappearing without leaving a scar. Under the 
microscope the parasite is plainly discernible. 

Symptoms. Barbers' itch begins as an attack of tinea circinata 
— as one or more reddish, scaly patches. Soon the redness and des- 
quamation become more decided, attended with swelling and indura- 
tion. The hairs will also be dry, brittle, inclined to break, and many 
of them are already loose. The process rapidly increases, the skin 
becomes distinctly nodular and lumpy, and points of pustulation de- 
51 



602 PRACTICE OF MEDICINE. 

velop about the openings of the hair-follicles. The subcutaneous con- 
nective tissue is also involved, giving rise to thick, firm masses of in- 
duration. 

The surface has a dark-red or purplish color, and is studded with 
variously sized tubercles and pustules. In some instances the num- 
ber of tubercles are in excess, while in others the pustules are more 
numerous, numbers of them discharging, and are succeeded by thick, 
crusts, which are often so abundant as to simulate pustular eczema. 

The hairs are always diseased, and break off either in the follicles 
or just above the level of the surface. Those not breaking drop out, 
leaving the region partly or wholly devoid of hair. 

The most frequent location attacked is the chin, neck, and sub- 
maxillary region. One or, what is more common, both sides of the 
face are involved. 

Itching, burnifig, pain, and swelling always accompany the affec- 
tion, varying in intensity from moderate to very severe. 

The course of the affection is usually chronic. Relapses are fre- 
quent, unless most thoroughly eradicated. 

Diagnosis. Sycosis non-parasitic a occasions difficulty of diag- 
nosis at times. The points of difference, however, are usually so 
marked that error should not occur. 

Sycosis non-parasitica is a chronic, inflammatory, non-contagious 
affection of the hair-follicles, characterized by the development of 
papules and pustules which are perforated with hairs, the hairs them- 
selves being unaffected. The upper lip, cheeks, and chin are the 
parts mostly involved. If of long duration, some inflammatory 
thickening results. 

In tinea sycosis, or sycosis parasitica, the skin and subcutaneous 
connective tissue are extensively involved, as manifested by the in- 
duration and formation of the characteristic tubercles. The upper 
lip is rarely invaded ; the hairs are diseased, broken off, or loose, and 
under the microscope reveal the parasite. 

Pustular eczema resembles tinea sycosis, with extensive pustulation 
and crusting; but in the former the hairs are not involved, nor are 
the characteristic tubercles present. 

Treatment. Local measures are sufficient for the cure of tinea 
sycosis. In the majority of instances the following procedure will 
effect a cure in three or four weeks. If crusts are present, — and almost 
always some are, — they are to be thoroughly saturated with inunctions 



DISEASES OF THE SKIN. 603 

of almond or olive oil, and removed by washing with soft soap and 
water. The part is then cleanly shaved, the first operation being 
more painful than subsequent ones. After shaving, the affected sur- 
face is bathed for ten minutes in water as hot as can be borne. 
All pustules are then opened with a fine needle, and the parts 
sponged freely for several minutes with a solution of sodii hypo- 
sulphitis, 3} (4 Gm.) ; agues, f gj (30 Cc.) ; after which the parts are 
again thoroughly washed with hot water, carefully dried, and smeared 
with an unguentumsulphuris, containing 3j-ij (4-8 Gm.)to the ounce. 
This procedure is preferably performed at night. The following 
morning the ointment is washed off with soap and water, the face 
bathed with the sodium solution, and dusted with any inert powder. 
This plan continued faithfully every night, omitting the shaving when 
the beard has not grown much, will usually be followed with success. 

Cases resisting the above means should, in addition, have the 
hairs depilated, the shaving performed every two or three days, 
thus allowing time for the hairs to grow sufficiently to depilate, 
the operation seldom being as painful as one would suppose. Shaving 
and depilation upon alternate days should be faithfully practised 
until the new hairs are healthy. 

In addition to the parasiticides mentioned, any of those recom- 
mended for the other vegetable parasitic diseases may be used. 



TINEA VERSICOLOR. 

Synonyms. Pityriasis versicolor ; liver-spots. 

Definition. A contagious, parasitic affection of the skin, due to 
the microsporon furfur ; characterized by the occurrence of variously 
sized, irregularly shaped, dry, slightly furfuraceous, yellowish spots 
upon the chest or other portions of the body. 

Cause. Pityriasis versicolor is the result of the presence upon the 
surface of the skin of a vegetable fungus termed microsporon furfur. 
It is a mildly contagious affection seen after puberty. It is said to 
occur most frequently in those suffering from wasting diseases, partic- 
ularly phthisis pulmonalis. It is not connected with any affection of 
the liver, as supposed by the laity. 

Pathology. The fungus permeates the horny layer of the 
epidermis, never the hairs or nails, and gives rise to the irregular- 



604 PRACTICE OF MEDICINE. 

shaped and sized maculae, of a yellowish or brownish color. As a 
rule, it gives rise to neither hyperemia nor inflammatory symptoms. 

Symptoms. Tinea versicolor occurs in the form of irregular, 
roundish, circumscribed, or reticulated maculae. The spots vary in 
size from that of a small silver coin to that of the hand. By coa- 
lescing they often cover a greater portion of the chest, their most 
usual site. Upon close inspection the surface of the macule is seen to 
be covered with furfuraceous scales, and, if the scales be not visible, 
scraping with the finger-nail will demonstrate their presence. In 
color the spots vary from a delicate buff or fawn shade to a yellowish, 
deep brown, and, rarely, even blackish hue. At times mild itching 
accompanies the eruption. 

Diagnosis. The character of the eruption is so distinct that 
errors in diagnosis can hardly occur. If any doubt exist, a few 
of the scales upon a glass slide, with a drop of liquor potasses, and 
covered with a thin glass cover and placed under a microscope 
with a power of from two hundred and fifty to five hundred diameters 
will readily determine the presence of the fungus. 

Prognosis. Favorable. 

Treatment. Mild galvanism over the discolorations is valuable. 
The parts should be cleansed with soap and water and either of the 
following lotions applied : 

R. Sodii sulphitis, . giij 12. Gm. 

Glycerini, f.^'j 8. Cc. 

Aquoe, . ad f^iv ad 120. Cc. M. 

Sic;. — Apply frequently. 

Or— 

&. Hydrargyri chlorid. corrosiv., . gr. iv o. 26 Gm. 

Alcoholis, . f^vj 24. Cc. 

Ammonii chloric!., % ss 2. Gm. 

Aquoe rosae, ad f^yj ad 180. Cc. M. 

SlG. — Apply frequently. (Tilbury Fox.) 

SCABIES. 

Synonym. The itch. 

Definition. A co?ilagious, animal parasitic disease of the skin, 
due to the acarus, or sarcoptes scabiei ; characterized by the formation 
of cuniculi (burrows), papules, vesicles, and pustules; followed by 
excoriations, crusts, and general cutaneous inflammation, and accom- 
panied by itching. 



DISEASES OF THE SKIN. 605 

Cause. Contagion. The only cause is the presence of the ani- 
mal parasite, the acarus> or sarcoptes scabiei. The affection occurs at 
all ages and in every walk of life. 

Pathology. Scabies is an inflammation of the skin with the 
development of papules, vesicles, pustules, excoriations, and subse- 
quent crusting, the result of the ravages of the animal parasite, 
together with the irritation produced by the scratching of the patient. 

The parasite acarus, or sarcoptes scabiei, is a minute creature, 
barely visible to the naked eye as a yellowish-white, rounded body. 
The female is the most commonly met with ; the males are said to 
take no part in causing the affection, and so are rarely seen. They 
are said to die in about a week after copulation with the female. The 
female finds her way by boring through the horny layer into the 
mucous layer of the epidermis, and, being impregnated, begins at 
once laying her eggs and at the same time making her burrow. 
A variable number of eggs are deposited, usually about a dozen, after 
which she perishes in the skin. The ova hatch out in six or ten 
days. 

Symptoms. Scabies is an artificial dermatitis or eczema, accord- 
ing to the amount of irritation produced by the presence of the 
parasite and the traumatism resulting from the severe scratching of 
the patient. 

Immediately upon the arrival of the itch mite upon the skin it begins 
its work of burrowing, and very soon a burrow, or cuniculus, is formed, 
in which the eggs are deposited, and which also becomes the habitat 
of the female during the remainder of her life. The ova are hatched 
in about one week after their deposit, and at once begin to care 
for themselves and to burrow, resulting in the formation of as many 
additional cicniculi as there are active female mites. It is the presence 
of these burrowing parasites that constitutes the irritation resulting in 
the inflammation of the skin, characterized by the formation of minute 
papules, vesicles, and pustules, with more or less inflammatory indura- 
tion. Add to these the excoriations, scratch marks, Jissures, torn 
vesicles, and pustules with yellow and bloody crusts, caused by the 
scratching, and a picture of the fully developed disease is seen. 

The burrow, or cuniculus, as it is termed, is formed by the mite 
entering and making its way beneath the horny layer of the epidermis, 
which is raised, very much as a mole undermines the ground. It 
occurs as a slight linear elevation of the epidermis, varying from a 



606 PRACTICE OF MEDICINE. 

half a line to four or five lines in length, and having an irregular or 
tortuous course. Its color is whitish or yellowish, speckled here and 
there with dark dots. At either end the cuniculus terminates as 
darkish points, the more prominent of which represent the parasite. 

The papules are the first inflammatory lesion, are numerous and 
of small size, and may be the extent of the disease. 

The vesicles are the next stage, varying in size and number, having 
an inflamed base, sometimes presenting cuniculi upon their summits. 

The pustules represent the completion of the inflammatory action, 
their size and number varying with the severity of the irritation. 

The intense itching, which is worse at night, results in excoriations, 
torn papules, vesicles, and pustules, followed by crustings, which 
after a time disguise the characteristic lesions. The regions of the 
body attacked are the hands, especially the sides of the fingers and 
the folds where they join the hands. After a time the wrists, penis, 
and mammae, and around about and upon the nipples, are invaded. 

Persons predisposed to eczema have this affection developed, in 
addition to the simple dermatitis, by the ravages of the itch mite. 

Diagnosis. A case of scabies seen before irritated by scratching 
presents no difficulty in diagnosis. The presence of the burrows 
always suffices for the diagnosis, but these are not always discover- 
able. The location of the eruption always points strongly to scabies. 
A history of contagion is of value. All doubt can be set at rest by 
the aid of the microscope. 

Prognosis. Always favorable, relapses only occurring when the 
treatment has been imperfectly carried out or when the individual 
has recontracted the disease. 

Treatment. Local measures are alone required in the treatment 
of scabies. The strength of the parasiticides must be controlled by 
the severity of the inflammatory symptoms present. If eczema com- 
plicate scabies, it is to be treated as an ordinary attack after the death 
of the itch mites. 

Scabies always succumbs to the following plan : The patient is to 
be thoroughly washed with soft soap and water, followed by a warm 
bath, after which cover eruption with tinctura benzoini, which imme- 
diately modifies the itching, or one of the following ointments is to be 
thoroughly rubbed into every portion of the body, especial attention 
being devoted to the hands, fingers, and other parts usually the 
seat of the disease : 



DISEASES OF THE SKIN, 

R . Styracis liquidis, fgij 

Ung. sulphuris, g ij-iv 

Ung. petrolei, ad Hjj ad 

SlG. — Apply after washing. (Bulkley.) 

Or— 

& . Sulphuris sublimat. , gj 

Balsam Peruviani, g ss 

Adeps, gj 

SlG. — For children. (Duhring.) 

Or— 

R . Creolini, gr. x 

Ung. petrolei, ^ ij 

SlG. — Apply thoroughly. 



G07 



8. 


Cc. 


16. 


Gm 


3o. 


Gm 



4. Gm. 

2. Gm. 

30. Gm. 



0.6 Cc. 

60. Gm. 



M. 



M. 



M. 



PEDICULOSIS. 

Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. 

Definition. A contagious, animal parasitic disease of the head, 
body, or pubes, due to the presence of pediculi and characterized by 
the wounds inflicted by the parasite, together with excoriations and 
scratch marks. 

Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis 
pubis. 

Cause. The cause is the presence of the parasite, the result of 
contagion, direct or indirect. The view of " a spontaneous genera- 
tion " of pediculi is not accepted by the great majority of observers. 

Pathology. The lesion produced by the presence of the pediculi 
is a minute hemorrhage, caused by the parasite inserting its sucking 
apparatus, or, as it is termed, its haustellum, into a follicle, and obtain- 
ing blood by a process of sucking, and not by biting, as is generally 
supposed. The presence of the parasite in any great numbers brings 
about a peculiar irritable state of the skin, which gives rise to an irre- 
sistible desire to scratch, as a consequence of which the surface is 
markedly excoriated and lacerated. 

Symptoms. The symptoms which arise from the presence of the 
parasite in different localities are somewhat different, and call for 
separate consideration. 

Pediculosis capitis. This variety is caused by the presence of the 
pediculus capitis, or head louse. The ova, or nits, are readily recog- 



COS PRACTICE OF MEDICINE. 

nized at a distance. Their favorite seat is the occipital region, either 
upon the surface of the scalp or upon the hair. Their presence gives 
rise to considerable irritation, itching, and consequent scratching, re- 
sulting in the wounding of the scalp, with oozing of a serous or puru- 
lent fluid mixed with blood, which soon mats the hair and forms into 
crusts. In those predisposed to eczema the presence of the parasite 
will give rise to that condition. 

The general health is usually unaffected by the presence of the 
pediculi. 

Pediculosis corporis. This variety of the pediculosis is caused by the 
presence of the pediculus corporis, or body louse, or more properly 
termed the pediculus vestimenti, or clothes louse. Its color, when 
devoid of blood, is dirty-white or grayish, with a dark line around the 
margin of its abdomen. Its habitat is the clothing covering the 
general surface, remaining upon the skin only long enough to obtain 
sustenance. The ova are usually deposited in the seams of the cloth- 
ing, the lice being hatched within the week. Occasionally a few of 
the pediculi may be observed crawling about the surface, or in the 
act of drawing blood. As they move over the surface they give rise 
to an intensely disagreeable itching sensation, to relieve which the 
patient scratches, which in turn gives rise to the characteristic lesions 
of the affection. 

The lesions are numerous. The scratch marks are scattered here 
and there, either long and streaked, in other places short and jagged, 
the excoriations and blood-crusts varying in size from a pin-head to a 
split pea or even larger, with irregular-shaped pustules. In addition 
to the lesions resulting from the scratching are seen the primary 
lesions, consisting of minute, reddish puncta with slight areolae, the 
points at which the parasite has drawn blood. In cases of longstand- 
ing a brownish pigmentation of the whole skin may result from the 
long-continued irritation and scratching. The favorite site of the 
lesions are the back, especially about the scapular region, the chest, 
abdomen, hips, and thighs. 

Pediculosis is seen most commonly among the poorer classes, and 
especially the middle-aged and elderly. 

Pediculosis pubis. This variety of pediculosis is caused by the pres- 
ence of the pediculus pubis, or crab louse. Although having its seat 
of predilection about the pubes, it may also infest the axillae, sternal 
region in the male, beard, eyebrows, and even eyelashes. 



DISEASES OF THE SKIN. 609 

They may be found crawling about the hairs, but more commonly 
hugging the surface closely. They infest adults chiefly, and occasion 
symptoms similar to those described in connection with other species. 
They are usually contracted through sexual intercourse, although 
occasionally they are present in cases in which they have not been 
communicated in this way, and where no explanation as to the mode 
of contagion can be suggested. The itching varies from slight to 
severe. 

Diagnosis. When violent itching exists in any case, without 
marked eruption, the possibility of the presence of pediculi should 
always be entertained, and if carefully sought after, are found. 

Prognosis. Favorable, if the treatment be thoroughly carried out. 

Treatment. Local measures alone are all that is necessary for 
the removal of the various forms of pediculosis. 

Pediculosis capitis. The most effective application to this variety 
is to thoroughly soak the head two or three times a day with ordinary 
petroleum or kerosene oil, and keep it wrapped in a cloth for twenty- 
four hours. At the end of this time the head should be thoroughly 
washed with soft soap and hot water, dried, and saturated with the 
official unguentum hydrargyri ammoniatum. If required, this entire 
procedure may be repeated, but usually any pediculi escaping the 
petroleum are destroyed by the unguentum. 

Pediculosis corporis. In this variety the habitat of the parasite 
being the clothing, they must be boiled or baked at a temperature 
sufficiently high to destroy their life. After this the clothing should 
be changed every day or two, carefully inspected, and if pediculi are 
seen, they must again be baked or boiled. It is folly to expect satis- 
factory results unless these directions are faithfully adhered to. For 
the irritation, itching, and excoriations, mild alkaline baths or lotions 
of acidum carbolicum are sufficient. 

Pediculosis pubis. The parts should be washed twice daily with 
soft soap and water, after which the thorough application of tinctura 
cocculus indiats, full strength or diluted, or a lotion of hydrargyri 
chloridum corrosivum or unguentum hydrargyri ammoniatum 01 
unguentum hydrargyri (blue ointment), will be effectual. 



5- 



INDEX 



Abdominal dropsy, 141 

typhus, 22 
Abscess, cerebral, 424 

iliac, 129 

of the heart, 383 

of the liver, 153 

perityphlitis 129 
Acne. 574 

artificialis, 575 

disseminata, 574 

indurata, 574 

papulosa, 574 

punctata, 534, 574 

pustulosa, 574 

rosacea, 576 

sebacea, 531 

tubercula, 574 

vulgaris, 574 
Acute articular rheumatism, 219 

Bright' s disease, 168 

diarrhcea, 109 

gastric catarrh, 76 

general diseases, 209 

hepatitis, 153 

meningitis, 404 

nasal catarrh, 263 

toxic gastritis, 78 

uraemia, 183 

yellow atrophy, 154 
Addison's disease, 203, 584 
Agraphia, 429 

amnesic, 429 
Ague, 39 

brow, 39 

cake, 39 

dumb, 39 
Albumin, tests for, 161 

nitric-magnesian test, 161 



Albuminuria, 169 

chronic, 1 71 
Alcoholism, 436 

acute, 436 

chronic, 443 
Amygdalitis, 272 
Amyloid kidney, 180 
Anaematosis, 199 
Anaemia, 195 

Blaud's pill for, 198 

cerebral, 414 

England's pill for, 198 

essential, 197 

lymphatic, 202 

of fatty heart, 199 

progressive pernicious, 199 

splenica, 201 
Anatomy, morbid, 1 1 
Aneurism of the abdominal aorta, 400 

of the arch of aorta, 399 

of the thoracic aorta, 399 
Angina catarrhalis, 269 

pectoris, 393 
Anidrosis, 540 
Anthrax, 571 

Aorta, aneurism of the, 398 
Aphasia, 429 
Aphonia, 429 
Aphthae, 69 

confluens, 69 

discrete, 69 
Aphthous stomatitis, 69 
Apncea, 14 
Apoplexy, 415 

capsular, 417 

cortical, 417 

crus-cerebri, 417 

ingravescent, 416 



611 



612 



INDEX. 



Apoplexy, serous, 446 

Appendicitis, 129 

Argyria, 584 

Arrhythmia, 393 

Arteries, Cohnheim's terminal, 421 

Arterio- capillary fibrosis, 396 

Arterio-sclerosis, 396 

Arthritis deformans, 227 

Artisans' cramp, 500 

Ascaris lumbncoides, 137 

Ascites, 144 

Asthenia, 14 

Asthma, 302 

bronchial, 302 

hay, 306 

Kopp's, 286 

Millar's, 286 

spasmodic, 302 

thymic, 286 
Ataxia, locomotor, 467 
Ataxic paraplegia, 470 
Atheroma, 396 

iodides in, 398 
Atonic dyspepsia, 96 
Atrophic paralysis of children, 458 
Atrophy, chronic spinal muscular, 462 

progressive muscular, 462 
Atropia for hemorrhage, 315 
Auscultation, 252 

Da Costa's rules for, 252 
Autumnal catarrh, 306 

fever, 22 

Bacillus, comma, 239 

malaria, 39 

of Eberth, 23 

of Pfeiffer, 19 

tuberculosis, 332 
Bacteria of decomposition, 239 
Bacteriology, II 
Barber's itch, 601 
Basedow's disease, 495 
Basham's iron mixture, 171 
Bell's palsy, 483 
Belt, hydropathic, 152 
Beri-beri, 476 
Bile, test for, 147 

pigment, test for, 147 
Biliary calculi, 149 
Bilious cholera, 113 

fever, 42,71 



Bilious malignant fever, 48 

remittent fever, 42 
Biliousness, 151 
Black-heads, 534 
Bladder, catarrh of, 190 
Blaud's pill, 198 
Bleeders' disease, 204 
Blepharospasm, 484 
Blood, diseases of, 195 

test for, 163 

white cell, 201 
Bloody flux, 121 
Boil, 569 

Bothriocephalus latus, 134 
Bowels, inflammation of, 109 
Brachycardia, 392 
Bradycardia, 392 
Brain, congestion of, 412 
Brand's method, 30 
Break-bone fever, 67 
Bright's disease, acute, 168 

chronic, 1 71, 1 75, 180 
Bromidrosis, 537 

pedum, 537 
Bronchial catarrh, 290 

dilatation, 299 

hemorrhage, 313 
Bronchiectasis, 298 
Bronchitis, acute, 290 

capillary, 293, 328 

chronic, 298 

croupous, 296 

diphtheritic, 296 

fetid, 298 

fibrinous, 296 

membranous, 296 

peri-, 303 

plastic, 296 

secondary, 298 

senile, 298 
Broncho-pneumonia, 293, 328 
Bronchorrhagia, 313 
Bronchorrhcea, 298 
Bronzed-skin disease, 203 
Brow ague, 41 

C^CUM, inflammation of, 127 
Calculi, alternating, 188 

biliary, 149 

cutaneous, 535 

hepatic, 149 



INDEX. 



613 



Calculi, oxalate of lime, 1 88 

phosphatic, 1 88 

renal, 187 

uric acid, 18S 
Callositas, 586 
Cancer, gastric, 87 

hepatic, 158 
Cancrum oris, 75 
Carbolic acid in tetanus, 499 
Carbuncle, 571 
Carbunculus, 571 
Carcinoma, gastric, 87 

of the liver, 158 
Cardiac dilatation, 380 

fatty degeneration, 387 

hypertrophy, 377 

paralysis, 213 

valvular diseases, 369 
Cardialgia, 94 
Carditis, 383 

chronic, 384 
Catalepsy, 492 

Catarrh, acute bronchial, 290 
gastric, 76 
nasal, 263 

autumnal, 306 

chronic bronchial, 298 
gastric, 81 
nasal, 267 
1 contagious, 19 

dry, 298 

intestinal, 109 

mucous, 298 

of the bile-ducts, 147 

of the bladder, 190 

of the mouth, 68 

of the rectum, 131 

suffocative, 293 
Catarrhal enteritis, 109 

jaundice, 147 

laryngitis, 274 

nephritis, 167 

pneumonia, 328 

stomatitis, 68 

tonsillitis, 269 
" Catarrh sec" of Laennec, 299 
Cephalic tetanus, 498 
Cephalodynia, 224 
Cerebral abscess, 424 

anaemia, 414 

congestion, 412 



Cerebral embolism, 421 

fever, 464 

hemorrhage, 415 

hypercemia, 412 

softening, 416 

thrombosis, 421 

tumor>, 426 
Cerebro-spinal fever, 35 

neuroses, 484 

sclerosis, 471 
Cervico-brachial neuralgia, 480 
Cervico-occipital neuralgia, 480 
Cheyne-Stokes breathing, 388 
Chicken-pox, 63 
Child-crowing, 279 
Chills and fever, 39 
Chiragra, 229 
Chloasma, 583 

uterinum, 584 
Chlorides, test for, 161 
Chlorosis, 197 
Cholera, 239 

Asiatic, 239 

bilious, 113 

English, 113 

epidemic, 239 

infantum, 1 19 

malignant. 239 

morbus, 113 

spasmodic, 239 

sporadic, 1 13 

typhoid, 239 
Cholerine, 240 
Chorea, 484 

Huntington's, 485 

post-hemiplegic, 485 
Chromidrosis, 537 
Chronic dyspepsia, 81 

entero-colitis, 116 

gastric catarrh, 81 

gastritis, 81 

nasal catarrh, 267 

valvular disease, 369 
Circular insanity, 514 
Clavus, 587 
Clinical history, 12 
Cohnheim's terminal arteries, 42: 
Cold in the head, 263 
Colic, hepatic, 149 

intestinal, 102 

lead, 103 



614 



INDEX. 



Colic, ovarian, 103 

renal, 187 

stomachic, 94 

uterine, 103 
Colitis, 121 

ulcerative, 121 
Coma, 14 

ursemic, 183 
Comedo, 534 
Comedones, 534 
Congestion, cerebral, 412 

of the kidneys, 167 

of the liver, 151 

of the lungs, 316 

spinal, 449 
Congestive fever, 44 
Constipation, 104 
Consumption, pulmonary, 332 

galloping, 332 

throat, 288 
Contagious fever, 1,1, 

catarrh, 19 
Convulsions, uremic, 183 
Cor bovinum, 371 
Corns, 587 
Corrigan's disease, 340 

hammer, 442 

sign, 89 
Coryza, acute, 263 

chronic, 267 
Costiveness, 104 
Cough, whooping, 308 

winter, 298 
Cow-pox, 63 
Crisis, 13 
Croup, catarrhal, 279 

false, 279 

membranous, 281 

pseudo-, 286 

spasmodic, 279 

true, 281 
Croupous bronchitis, 296 

enteritis, 112 

laryngitis, 281 

pneumonia, 319 

stomatitis, 69 
Cyst, renal, 182 

sebaceous, 536 
Cysticercus bovis, 135 

cellulosus, 134 
Cystitis, 190 



Cystitis, acute, 190 
chronic, 190 

Dandruff, 531 
Dandy fever, 67 
Death, 14 

Delirium tremens, 438 
Delusional insanity, 516 
Dementia, 527 

acute, 528 

alcoholic, 529 

apoplectica, 529 

choreica, 529 

chronic 529 

epileptic, 513, 529 

organic, 529 

paralytica, 529 

paretic, 521 

partial, 530 

primary, 530 

secondary, 530 

senilis, 530 

syphilitica, 530 

toxica, 530 
Dengue, 67 
Diabetes insipidus, 236 

mellitus, 232 
Diagnosis, 14 

by exclusion, 14 

differential, 14 

direct, 14 

physical, 244 
Diarrhoea, 106 

acute, 106, 109 

bilious, 106 

choleriform, 1 19 

chronic, 106 

feculent, 106 

inflammatory, 115 

lienteric, 106 

mixture, Squibb's, 108 
Diathesis, 12 
Dilatation, bronchial, 299 

cardiac, 380 

gastric, 90 
Diphtheria, 210 

bronchial, 296 

laryngeal, 213, 28 1 

nasal, 213 
Diphtheritic paralysis, 213 

stomatitis, 70 



INDEX. 



G15 



Dipsomania, 439 

Discharges, chopped spinach, 116 

rice water, 1 10, 1 14 
Disease, 9 

acute, 13 

Addison's, 203, 584 

Basedow's, 495 

bleeders', 204 

Bright's, 168, 171, 175, 180 

causes of, II 

chronic, 13 

Corrigan's, 340 

defined, 9 

Duchenne's, 465 

fish-skin, 590 

flesh-worm, 138 

Fothergill's, 479 

functional, 9 

Graves', 495 

Hodgkin's, 202 

Meniere's, 431 

organic, 9 

Parkinson's, 501 

predisposition to, 12 

subacute, 13 

termination of, 13 
Diseases, acute, general, 209 

general or nutritional, 484 

mental, 504 

of the biliary passages, 147 

of the blood, 195 

of the bronchial tubes, 290 

of the cerebral membranes, 402 

of the cerebrum, 409 

of the circulatory system, 352 

of the intestinal canal, 99 

of the kidneys, 159 

of the larynx, 274 

of the liver, 151 

of the lungs, 316 

of the mouth, 68 

of the nasal passages, 263 

of the nerves, 475 

of the nervous system, 401 

of the peritoneum, 140 

of the pharynx, 269 

of the pleura, 346 

of the respiratory system, 244 

of the skin, 531 

of the spinal cord, 449 

of the stomach, 76 



Disorders of secretion, 531 
Dizziness, 431 
Dobell's solution, 54 
Dropsy, cutaneous, 52 

of the abdomen, 141 

of the pleura, 350 

pericardial, 364 

peritoneal, 141 

pleural, 350 
Duchenne's disease, 465 
Duodenitis, 109 
Dysentery, acute, 121 

chronic, 124 

croupous, 121 

epidemic, 122 

nuclein in, 126 

sporadic, 122 

washing rectum in, 126 
Dyspepsia, 96 

acid, 97 

atonic, 96 

chronic, 81 

drunkards', 81 

flatulent, 97 

hot water in, 78 

intestinal, 99 

irritative, 97 

nervous, 97 

Ecstasy, 492 
Ecthyma, 568 
Eczema, 542 

acute, 543 

ani, 555 

aurium, 554 

barbae, 553 

capitis, 551 

chronic, 545 

erythematosum, 543 

faciei, 552 

fissum, 545 

genitalium, 554 

impetiginosum, 544 

intertrigo, 555 

labiorum, 552 

madidans, 544 

mammarum, 556 

palmarum, 556 

palpebrarum, 553 

papillomatosum, 545 

papillosum, 543 



6] 6 



INDEX. 



Eczema plantarum, 556 

pustulosum, 544 

rimosum, 545 

rubrum, 544, 549 

sclerosum, 545 

squamosum, 545 

unguium, 557 

verrucosum, 545 

vesiculosum, 544 
Elixir, triple, 389 
Embolism, cerebral, 421 
Emphysema, 310 
Empyema, 347 
Encephalitis, acute, 424 

suppurative, 424 
Endarteritis chronica deformans, 396 
Endocarditis, acute, 364 

chronic, 369 

diphtheritic, 365 

malignant, 367 

mycotic, 367 

septic, 367 

ulcerative, 367 
Enteralgia, 102 
Enteric fever, 22 
Enteritis, catarrhal, 109 

croupous, 112 

membranous, 1 12 
Entero-colitis, 115 
Entero-mesenteric fever, 22 
En tero ptosis, 92 
Enterorrhcea, I06 
Ephemeral fever, 1 7 
Epidemic catarrhal fever, 19 

cerebrospinal fever, 35 

roseola, 58 
Epilepsy, 486 

Jacksonian, 486 
Epileptic dementia, 513 

imbecility, 513 

insanity, 513 
Erysipelas, 64 

ambulans, 65 

of the brain, 65 

phlegmonous, 65 
Erysipelatous dermatitis, 64 
Erythema intertrigo, 541 

simplex, 540 
Erythematous stomatitis, 68 
Hrythromelalgia, 481 
Essential anaemia, 199 



Etiology, II 

Eucalyptol in cystitis, 193 
Exophthalmic goitre, 495 
Exudative endocarditis, 364 

Facial paralysis, 483 
Farcy, 218 
Fatty heart, 387 
Favus, 593 
Febricula, 17 
Fever, 15 

abdominal typhus, 22 

autumnal, 22 

bilious, 42, 76 

remittent, 42 
typhoid, 38 

breakbone, 67 

catarrhal, 19 

cause of, 15 

cerebral, 404 

cerebro-spinal, 35 

congestive, 44 

contagious, 33 

continued, simple, 17 

dandy, 67 

enteric, 22 

entero-mesenteric, 22 

ephemeral, 17 

epidemic cerebro-spinal, 35 

gastric, 22, 76 

hay, 306 

intermittent, 39 

irritative, 17 

jail, 33 

lung, 319 

malarial, 39 

malignant intermittent, 44 

remittent, 44 
marsh, 42 
Mediterranean, 48 
nervous, 22 
neuralgic, 67 
periodical, 39 
pernicious, 41 
relapsing, 38 
remittent, 42 
rheumatic, 219 
rose, 306 
sailors', 48 
scarlet, 51 
ship, 33 



INDEX. 



617 



Fever, simple continued, 17 

spirillum, 38 

spotted, 33 

swamp, 39 

thermic, 443 

typhoid, 22 

typho-malarial, 42 

typhus, 33 

winter, 319 

yellow, 48 
Fevers, 15 

continued, 1 7 

eruptive, 51 

general treatment of, 16 

periodical, 39 

pernicious malarial, 44 

primary cause of, 15 
Fibrosis, arterio-capillary, 396 
Fish-skin disease, 590 
Floating kidney, 193 
Folie circulaire, 514 
Fothergill's disease, 479 
Freckles, 583 
Furunculosis, 569 
Furunculus, 569 

Gall-stones, 149 
Gastralgia, 94 
Gastric cancer, 87 

carcinoma, 87 

dilatation, 90 

fever, 21, 76 

hemorrhage, 93 

neuralgia, 94 

ulcer, 84 

vertigo, 43 1 
Gastritis, acute toxic, 78 

chronic, 81 

subacute, 76 

toxic, 78 
Gastrodynia, 94 
Gastroptosis, 92 
Gastrorrhagia, 93 
General paralysis, 521 
German measles, 58 
Glanders, 218 
Glenard's disease, 92 
Glossitis, 73 
Glottis, oedema of, 277 

spasm of, 286 
Glycosuria, 232 



Glycosuria, simple, 234 
Gonagra, 229 
Gout, 229 

rheumatic, 227 
Gravel, 187 
Graves' disease, 495 
Green sickness, 197 
Gripes, 102 
Grutum, 535 

H.EMATEMESIS, 93 

Hematology, 11 

Hematoma of the dura mater, 403 

Hematuria, 188 

Haemophilia, 204 

Haemoptysis, 313 

Hay asthma, 306 

fever, 306 
Headache, 434 
Heart, anaemia of fatty, 199 

dilatation of, 380 

fatty degeneration of, 3S7 

hypertrophy of, 377 

irritable, 389 

neuralgia of, 393 

palpitation of, 389 

rapid, 390 

valvular diseases of, 369 
Heartburn, 96 
Heat exhaustion, 444 

stroke, 443 
Hemicrania, 434 
Hemiplegia, 417 
Hemorrhage, bronchial, 313 

cerebral, 415 

gastric, 93 

meningeal, 418 

pons, 417 

renal, 188 

ventricular, 417 
Hemorrhagic diathesis, 204 
Hemorrhcea petechialis, 206 
Hepatic calculi, 149 

cancer, 158 

colic, 149 
Hepatitis, acute, 153 

general parenchymatous, 154 

interstitial, 155 

parenchymatous, 153 

suppurative, 153 
Hernia, strangulated, 132 



6J 



INDEX. 



Herpes, 560 

circinatus, 595 

facialis, 560 

gestationis, 561 

praeputialis, 560 

progenitalis, 560 

tonsurans, 598 

zoster, 561 
Histology, II' 
Hives, 557 

Hodgkin's disease, 202 
Hooping cough, 308 
Hydrocephalus, acquired, 446 

acute, 407, 446 

chronic, 447 

congenital, 447 
Hydropericardium, 364 
Hydropneumothorax, 350 
Hydrosis, 537 
Hydrothorax, 350 
Hyperemia, cerebral, 412 

renal, 167 

spinal, 449 
Hyperemias of the skin, 540 
Hyperidrosis, 537 

local, 537 

unilateral, 537 
Hypertrophies of the skin, 583 
Hypertrophy, cardiac, 377 
Hypotonia, 469 
Hysteria, 489 
llystero-epilepsy, 492 

Ichthyosis, 590 
Icterus, 147 

hemorrhagic, 154 
Impetigo, 567 
Incubation, period of, 13 
Indigestion, 96 

acute, 76 

intestinal, 99 
Inebriety, 436 

Inflammation of the skin, 542 
Influenza, 19 
Insanity, 507 

alternating, 5 T 5 

chronic delusional, 520 

circular, 514 

delusional, 516 

epileptic, 513 

Kahlbaum's, 515 



Insolation, 443 
Inspection, 245 
Intercostal neuralgia, 561 
Intermittent fever, 39 

tetanus, 497 
Interstitial nephritis, 175 
Intestinal colic, 102 

dyspepsia, 99 

indigestion, 99 

obstruction, 132 

parasites, 1 34 

stricture, 132 

torpor, 104 
Intestines, diseases of, 97 
Introduction, 9 
Invagination, 133 
Ipecacuanha in dysentery, 126 
Iron lemonade, 196 
Irritative fever, 17 
Ischsemia, 195 
Itch, 604 

barber's, 601 

Jail fever, 53 
Jaundice, catarrhal, 147 
malignant, 154 

Kahlbaum's insanity, 515 
Kakke, 476 
Katatonia, 515 
Kidneys, amyloid, 180 

congestion of, 167 

contracted, 175 

diseases of, 159 

floating, 193 

gouty, 175 

lardaceous, 180 

movable, 193 

sclerosis of, 175 

small red, 175 

wandering, 193 

waxy, 180 

white, large, 171 

La Grippe, 19 
Laryngeal phthisis, 288 
Laryngismus stridulus, 286 
Laryngitis, acute catarrhal, 274 

croupous, 281 

cedemalous, 277 

spasmodic, 279 



INDEX. 



619 



Laryngitis, tuberculous, 288 
Larynx, diseases of the, 274 
Law of parallelism, 220 
Lentigo, 583 
Leptomeningitis, acute, 404 

spinalis, 452 
Lesions, II 
Leucaemia, 201 
Leucocytbemia, 201 
Lichen simplex. 543 

tropicus, 563 
Lithsemia, 237 
Lithiasis, 237 
Liver, abscess of, 153 

albuminous, 157 

amyloid, 157 

atrophy of, 156 

carcinoma of, 158 

cirrhosis of, 155 

congestion, 15 1 

diseases of, 15 1 

gin drinkers', 155 

hob-nailed, 155 

hypertrophic sclerosis of, 156 

lardaceous, 157 

nutmeg, 156 

sclerosis of, 155 

scrofulous, 157 

spots, 583, 603 

torpid, 151 

waxy, 157 

yellow atrophy of, 154 
Lock-jaw, 498 
Locomotor ataxia, 467 
Lousiness, 607 
Lumbago, 224 

Lumbo-abdominal neuralgia, 480 
Lumbodynia, 224 
Lungs, cirrhosis of, 340 

congestion of, 316 

consumption of, 338 

gangrene of, 320 

oedema of, 317 
Lymphadenoma, 202 
Lysis, 13 

Malari/E oscillaria, 11 
Malignant endocarditis, 367 

intermittent fever, 44 

jaundice, 154 
' remittent fever, 44 



Mai, le grand, 486 
Mai, le petit, 487 
Malarial fever, 39 
Mania, 507 

acute, 508 

delirious, 508 

amenorrhceal, 509 

asthenic, 509 

chronic, 5 10 

dancing, 509 

delusional, 509, 516 

erotic, 509 

epileptica, 509 

hallucinatory, 509 

homicidal, 509 

post-epileptic, 513 

pre-epileptic, 513 

puerperal, 510 

reasoning, 520 

recurring, 510 

senile, 510 

transitory, 510 
Mania-a-potu,438, 509 
Marsh fever, 42 
Measles, 56 

black, 57 

false, 58 

French, 58 

German, 58 
Mediterranean fever, 48 
Megrim, 434 
Melanaemia, 42 
Melancholia, 504 

agitata, 505 

attonita, 506 

chronic, 506 

delusional, 516 

hallucinatory, 505 

hypochondriacal, 505 

senile, 506 
Melasma supra-renalis, 203 
Melituria, 232 
Membranous enteritis, 112 
Meniere's disease, 432 
Meningitis, 403 

acute, 404 

basilar, 407 

cerebro-spinal, epidemic, 35 

spinal, 452 

tubercular, 407 
Mensuration, 247 



620 



INDEX. 



Metastasis, 14 
Migraine, 434 
Miliaria, 563 

alba, 563 

rubra, 563 
Milium, 535 

Mitral regurgitation, 369 
Mixture, Basham's iron, 171 

Brown- Sequard's, for epilepsy, 
488 

Da Costa's muscular cramp, 
114 

enterica, ill 

ferro-salicylata, 223 

Pepper's asthma, 304 

Philadelphia Hospital epileptic, 
488 

Smith's tonic, 196 

Squibb's diarrhoea, 108 
Monomania, 520 
Morbid anatomy, 1 1 
Morbilli, 56 
Morphina in acute unemia, 185 

in cardiac dilatation, 382 
Morphiomania, 510 
Mouth, catarrh of, 68 

diseases of, 68 

white, 72 
Movable kidney, 193 
Mucus, test for, 161 
Muguet, 72 
Mumps, 209 
Murmurs, aortic, 358 

endocardial, 356 

exocardial, 356 

mitral, 357 

pericardial, 356 

pulmonic, 358 

tricuspid, 358 
Muscular rheumatism, 224 
Myelitis, acute, 454 
Myocarditis, acute, 383 

chronic, 384 
Myxcedema, 502 

Nasal acute catarrh, 263 
chronic catarrh, 267 
passages, diseases of, 263 

Nephritis, acute desquamative, 16 5 
parenchymatous, 168 
catarrhal, 167 



Nephritis, chronic parenchymatous, 
171 

interstitial, 175 

peri-, 182 

pyelo-, 181 

suppurative, 181 

tubal, 168 
Nephro-lithiasis, 187 
Nephroptosis, 92 
Nephrosis, pyelo-, 182 
Nervous dyspepsia, 97 

exhaustion, 493 

fever, 22 

prostration, 493 
Nettle-rash, 557 
Neuralgia, 479 

cervico-brachial, 480 

cervico-occipital, 480 

dorso-intercostal, 480 

intercostal, 561 

lumbo-abdominal, 480 

of stomach, 94 

of the fifth nerve, 479 

of the heart, 393 

red, 481 

sciatic, 480 
Neuralgic fever, 67 
Neurasthenia, 493 
Neuritis, multiple, 476 

simple, 475 
Neuroses, occupation, 500 
Noma, 75 
Nomenclature, 10 
Nuclein in dysentery, 126 
Nymphomania, 509 
Nystagmus, 484 

Obstruction, aortic, 373 

intestinal, 132 

mitral, 373 

pulmonic, 375 

pyloric, 87 

tricuspid, 375 
Occlusion of cerebral vessels, 421 
Occupation neuroses, 500 
CEdema of glottis, 277 

of lungs, 317 
Oidium albicans, 72 
Oinomania, 437 
Oxyuris vermicularis, 137 
Ozsena, 267 



INDEX. 



621 



Pachymeningitis, 403 

hypertrophic, 451 

pseudo-membranous, 451 

spinalis, 451 
Pains, the girdle, 454 
Palpation, 246 
Palsy, Bell's, 483 

shaking, 501 

wasting, 462 
Paragraphia, 429 
Paralysis, 418 

agitans. 501 

alcoholic, 176. 

bilateral, 418 

bulbar, 461 

cardiac, 213 

chronic progressive bulbar, 461 

crossed, 418 

diphtheritic, 213 

essential, of children, 458 

facial, 483 

general, 521 

glosso-labio-laryngeal, 416 

infantile spinal, 458 

of the insane, general, 521 

o,f the tongue, 430 

pharyngeal, 213 

shaking, 501 

spastic spinal, 466 

unilateral, 418 

wasting, 462 
Paralytic dementia, 521 
Paranoia, 520 
Paraphasia, 424 
Paraplegia, ataxic, 470 
Parasites, intestinal, 134 
Parasitic diseases of the skin, 593 
Paresis, general, 521 
Parkinson's disease, 501 
Parotiditis, 209 

metastatic, 209 
Partial cerebral anaemia, 421 
Pathogenesis, II 
Pathognomonic, 13 
Pathology, 9 
Pediculosis, 607 

capitis, 607 

corporis, 608 

pubis, 608 
Peliosis rheumatica, 206 
Pemphigoid purpura, 207 



Pemphigus, 565 
Peptic ulcer, 84 
Percussion, 247 

auscultatory, 251 

respiratory, 251 
Perforating ulcer, 84 
Pericarditis, acute, 359 

chronic, 362 

. dl 7> 359 
Pericardium, adherent, 328 

hydro-, 329 
Peri-nephritis, 182 
Periodical fevers, 39 
Peripheral neuritis, 475 
Peri-proctitis, 131 
Peritoneal dropsy, 141 
Peritonitis, 140 
Peri-typhlitis, 1 29 
Pertussis, 308 
Pharyngeal paralysis, 213 
Pharyngitis, acute catarrhal, 269 

erysipelatous, 270 

exanthematous, 270 

fibrinous, 270 

gangrenous, 270 

phlegmonous, 270, 272 
Phosphates, tests for, 161 
Phosphoridrosis, 537 
Phthiriasis, 607 
Phthisis, 332 

acute, 332 

caseous, 335 

catarrhal, 335 

chronic, 338 

fibroid, 346 

florida, 336 

incipient, 338 

laryngeal, 288 

pneumonic, 332, 335 

pulmonalis, 332 

tubercular, 332, 338 
Physical diagnosis, 244 

signs, 12 

association of, 263 
Pill, Blaud's, 198 

Da Costa's, for hemorrhage, 315 

England's, 198 

Gross's neuralgic, 482 

Moussette's, 482 

Niemeyer's, 344 
Pilocarpus for spreading erysipelas, 66 



622 



INDEX. 



Pilocarpus for mumps, 210 

Pityriasis, 531 

versicolor, 603 
Pleurisy, 346 
Pleuritis, 346 

chronic, 347 
Pleurodynia, 225 
Pleuro-pneumonia, 319 

alcoholic, 322 

apyretic, 322 

aspiration, 323 
Pneumonia, bilious, 322 

caseous, 335 

catarrhal, 328 

chronic catarrhal, 329, 335 
interstitial, 340 

croupous, 319 

lobar, 319 

lobular, 328 

traumatic, 323 

typhoid, 322 
Pneumonitis, 319 
Pneumothorax, 350 
Podagra, 229 
Poliomyelitis anterior acuta, 45 S 

chronic, 462 
Polydipsia, 236 
Polyuria, 236 

Posterior spinal sclerosis, 467 
Predisposition, 12 

acquired, 12 

inherited, 12 
Prickly heat, 563 
Primaiy delusional insanity, 516 
Proctitis, 131 

peri-, 131 
Prodromes, 13 
Professional neuroses, 500 
PiT.gr.osis, 14 
Progressive muscular atrophy, 462 

pernicious anarinia, 199 
Pseudo-tabes, 476 
Psoriasis, 579 

circinata, 580 

diffusa 580 

guttata, 580 

gyrata, 580 

nummularis, 580 

of the mouth, 74 

of the tongue, 74 

palmar s, 5S0 



Psoriasis, plantaris, 580 

punctata, 580 

unguium, 580 
Psychalgia, 504 
Pulmonary engorgement, 316 

oedema, 317 

tuberculosis, 332 
Pulse, Corrigan, 371 

irregularity of, 393 

receding, 371 
Purging, 106 
Purpura, 206 

hemorrhagica, 2c6 

simplex, 206 

urticans, 206 
Pus, test for, 163 
Pyelitis, 181 
Pyelo-nephritis, I Si 
Pyelo-nephrosis, 182 
Pyloric obstruction, 90 

stenosis, 90 
Pyrosis, 96 



QUININA in trichinosis, 140 
in typhoid fever, 26 

Quinsy, 272 

malignant, 210 



Rales, 258 

Reactions of degeneration, 459 

Rectitis, 131 

Rectum, catarrh of, 131 

washing out the, 126 
Regurgitation, aortic, 370 

mitral, 369 

pulmonic, 372 

tricuspid, 372 
Relapsing fever, 2^ 
Remittent fever, 42 
Renal calculi, 187 

colic, 187 

cyst, 182 
Respiration, Cheyne-Stokes', 388 

oscillating, 388 
Respiratory system, diseases of, 244 
Rheumatic fever, 219 

gout, 227 
Rheumatism, acute articular. 219 

gonorrhfeal, 221 

hyperpyrexia of, 220 



INDEX. 



623 



Rheumatism, inflammatory, 219 

muscular, 224 
Rheumatoid arthritis, 227 
Rhinitis, acute, 263 

chronic, 267 
Rhinophyma, 577 
Ringworm, honeycombed, 593 

of the beard, 601 

of the body, 595 

of the scalp, 598 
Rontgen or X rays, 14 
Rosacea, acne, 576 
Rose, the, 64 
Rotheln, 58 
Round-worms, 137 
Rubella, 58 
Rubeola, 56 

Satlors' fever, 48 

Salisbury steaks, 83 

Sand, renal, 188 

Scabies, 604 

Scall, 542 

Scarlatina, 51 

Scarlet fever, 5 1 

Schonlein s disease, 207 

Sciatica, 480 

Sclerosis, amyotrophic lateral, 462 

ant ero lateral, 470 

cerebro-spinal, 471 

disseminated, 47 1 

hepatic hypertrophic, 156 

of the liver, 155 

posterior spinal, 467 

primary lateral, 466 

spinal, 465, 471 
Scorbutus, 205 
Scurvy, 205 
Sebaceous cyst, 536 
Seborrhoea, 531 

capitis, 532 

faciei, 532 

oleosa, 532 

sicca, 532 
Secondary processes, 13 
Secretions, disorders of, 531 
Shaking palsy, 501 
Shingles, 561 
Ship fever, 33 
Sick headache, 434 
Sickness, green, 197 



Sign, Corrigan's, 89 
Signs, 13 

physical, association of, 263 
Silver nitrate in phlegmonous erysip- 
elas, 67 

in purpura hemorrhagica, 208 
Skin, hyperemias of, 540 

inflammations of, 542 
Smallpox, 59 

Smith's, Dr. A. H., tonic, 196 
Sore throat, acute, 274 
Sounds, in disease, chest, 255 

in health, chest, 253 

normal cardiac, 353 
Spanemia, 195 
Spasm, histrionic, 484 

of the glottis, 286 
Spasmodic croup, 279 

tabes dorsalis, 466 
Spastic spinal paralysis, 466 
Spinal hyperemia, 449 

irritation, 493 

meningitis, 452 

sclerosis, 465 
Spinalis pachymeningitis, 451 
Spotted fever, 33 
Sprue, 72 

St. Anthony's fire, 64 
St. Vitus's dance, 484 
Stomach, cancer of, 87 

diseases of, 76 

neuralgia of, 94 

spasm of, 94 
Stomatitis, aphthous, 69 

catarrhal, 68 

croupous, 69 

diphtheritic. 70 

erythematous, 68 

follicular, 69 

gangrenous, 75 

parasitic, 70 

simple, 68 

ulcerative 70 

vesicular, 69 
Stonepock, 574 
Stricture, intestinal, 132 
Strychnin a in phthisis, 342 
Succussion, 262 
Sudamen, 539 
Sudamina, 539 
Sugar, test for, 164, 165 



624 



INDEX. 



Summer complaint, 119 
Sunstroke, 443 
Swamp fever, 39 
Sycosis parasitica, 601 
Symptoms, 12 
Syncope, 419 
Synocha, 17 
Syringomyelia, 474 

Tabes dorsalis, 467 
Tachycardia, 390 
Taenia saginata, 134 

solium, 134 
Tapeworm, armed, 134 

unarmed, 135 
Temulentia, 436 
Test for albumin, 161 

for bile, 163 

for bile pigment, 164 

for blood, 163 

for chlorides, 161 

for Ehrlich's diazo-reaction, 166 

for indican, 166 

for mucus, 161 

for phosphates, 1 61 

for pus, 163 

for sugar, 164, 165 

for urates, 1 60 

for urea, 160 
Tetanilla, 497 
Tetanus, 498 
Tetany, 286, 497 
Tetter, 542 
Thermic fever, 443 
Throat, acute sore, 274 

consumption, 288 

putrid sore, 210 
Thrombosis, cerebral, 421 
Thrush, 72 
Tic-douloureux, 479 
Tinea circinata, 595 

favosa, 593 

furfuracea, 531 

kerion, 599 

sycosis, 601 

tonsurans, 598 

versicolor, 603 
Tinkling, metallic, 261 
Tone, bandbox, of Bamberger, 304 
Tongue, strawberry, 52 
Tonsillitis, acute, 272 



Tonsillitis, catarrhal, 269 
Tormina, 102 
Torticollis, 225 
Toxic gastritis, 78 
Trance, 492 
Treatment, 14 

abortive, 14 

expectant, 15 

palliative, 15 

preventive, 14 

restorative, 15 
Tremens, delirium, 438 
Trichinae, 138 

spiralis, 1 38 
Trichinosis, 138 
Trismus, 498 

Trousseau's diuretic wine, 171 
Tubbing in typhoid fever, 30 
Tubercular meningitis, 407 
Tuberculosis, 338 

acute miliary, 332 
Tuberculous laryngitis, 288 
Tumor, phantom, 492 

sebaceous, 536 
Tumors, abdominal, 89 

intra-cranial, 426 
Turpentine in purpura, 208 
Tympanites, chronic, 146 
Typhlitis, 127 
Typho-malarial fever, 42 
Typhoid fever, 22 
Typhus fever, ^^ 

Ulcer, duodenal, 86 

gastric, 84 

perforating, 84 
Ulcerative colitis, 121 

stomatitis, 70 
Ulcerosa gingivitis, 70 
Uraemia, acute, 183 

* morphina in, 185 
Uraemic coma, 183 

convulsions, 183 

intoxication, 183 
Urates, test for, 160 
Urea, test for, 160 
Uric acid diathesis, 237 

test for, 1 60, 161 
Uridrosis, 537 
Urine, 159 

hysterical, 303 



INDEX. 



625 



Urine, normal color, 159 
constituents, 159 
quantity, 159 
reaction, 159 
Urticaria, 557 

Vaccination, 63 

Vaccinia, 63 

Valvular diseases of the heart, 

diagnosis of, 375 
Valvulitis, 364 
Varicella, 63 
Variola, 59 
Verruca, 588 
Verrucktheit, 520 
Vertigo, 431 

auditory, 431 

aural, 431 

gastric, 431 

nervous, 431 

senile, 431 

stomachic, 82, 431 
Vesicular emphysema, 310 
Voice in disease, 261 

in health, 254 
Vomit, black, 49 

coffee-ground, 49 



369 



Waddle, the, 467 
Warburg's tincture, 46 
Wart, 588 

venereal, 589 
Wasting palsy, 462 
Water blisters, 565 

cancer, 75 
Wen, 536 
Wheals, 558 
White blood, 201 

cell blood, 201 

mouth, 72 
Whooping-cough, 308 
Widal reaction, 27 
Wilson's, Erasmus, tonic, 533 
Winter cough, 319 
Worms, round, 137 

seat, 137 

tape-, 134 

Xeroderma, 591 

Yellow fever, 48 
Jack, 48 

Zona, 561 



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SUBJECT. PAGE 

Alimentary Canal (see Surgeiy) 19 

Anatomy (see Miscellaneous).. 14 

Anesthetics 3 

Autopsies (see Pathology) 16 

Bacteriology (see Pathology).. 16 

Bandaging (see Surgery) 19 

Brain 4 

Chemistry 4 

Children, Diseases of 6 

Clinical Charts 6 

Compends 22, 23 

Consumption (see Lungs) 11 

Dentistry 7 

Diagnosis 17 

Diagrams (see Anatomy, page 
3, and Obstetrics, page 16). 

Dictionaries 8 

Diet and Food (see Miscella- 
neous) 14 

Dissectors 3 

Domestic Medicine 10 

Ear 8 

Electricity 9 

Emergencies (see Surgery) 19 

Eye 9 

Fevers ., 9 

Gout 10 

Gynecology 21 

Hay Fever 20 

Heart 10 

Histology 10 

Hospitals (see Hygiene) 11 

Hygiene 11 

Insanity 4 

Latin, Medical (see Miscella- 
neous and Pharmacy) 14, 16 

Lungs 12 

Massage 12 

Materia Medica 12 

Medical Jurisprudence 13 

Microscopy 13 

Milk Analysis (see Chemistry) 4 

Miscellaneous 14 

Nervous Diseases 14 



SUBJECT. PAGE 

Nose 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9 

Osteology (see Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical Diagnosis 17 

Physical Training (see Miscel- 
laneous) 14 

Physiology 18 

Poisons (see Toxicology) .* 13 

Popular Medicine 10 

Practice of Medicine 18 

Prescription Books 18 

Railroad Injuries (see Nervous 

Diseases) 14 

Refraction (see Eye) 9 

Rheumatism 10 

Sanitary Science 11 

Skin 19 

Spectacles (see Eye) 9 

Spine (see Nervous Diseases) 14 
Stomach (see Miscellaneous)... 14 

Students' Compends 22, 23 

Surgery and Surgical Dis- 
eases 19 

Syphilis 21 

Technological Books 4 

Temperature Charts 6 

Therapeutics 12 

Throat 20 

Toxicology 13 

Tumors (see Surgery) 19 

U. S. Pharmacopoeia 16 

Urinary Organs 20 

Urine 20 

Venereal Diseases 21 

Veterinary Medicine 21 

Visiting Lists, Physicians'. 

{Send for Special Circular.) 
Water Analysis (see Chemis- 
try) 5 

Women, Diseases oi 21 



The prices as given in this Catalogue are net. Cloth 
binding, unless otherwise specified. No discount can be 
allowed under any circumstances. Any book will be sent, 
f>ottf>aid. u-frnn receipt of advertised ■{ vice. 



SUBJECT CATALOGUE OF MEDICAL BOOKS. 3 

#3* All books are bound in cloth, unless otherwise speci- 
fied. All prices are net. 

ANATOMY. 

MORRIS. Text-Book oi Anatomy. 2d Edition. Revised and 
Enlarged. 790 Illustrations, 214 of which are printed in coiors. 
Just Ready. Cloth, $6.00 ; Leather, $7.00 ; Half Russia, $8.00 

'* Taken as a whole, we have no hesitation in according very high 
praise to this work. It will rank, we believe, with the leading Anato- 
mies. The illustrations are handsome and the printing is good."— 
Boston Medical and Surgical Journal. 

Handsome Circular of Morris, with sample pages and colored illus- 
trations, will be sent free to any address. 

BROOMELL. Anatomy and Histology of the Human Mouth 
and Teeth. 284 Illustrations. #4 50 

DEAVER. Surgical Anatomy. A Treatise on Human Anatomy 
in its Application to Medicine and Surgery. With about 400 very 
Handsome full-page Illustrations Engraved from Original Drawings 
made by special Art'sts from dissections prepared for the purpose. 
Three Volumes. Royal Square Octavo 
Cloth, $2i.co; Half Morocco or Sheep, #24 od ; Half Russia, $27.00 

ECKLEY. Practical Anatomy. A Manual for the use of Students 
in the Dissecting Room. Based upon Morris' Text-Bookof Anatomy 
and Including a Section on the Fundamental Principles of Anatomy. 
With 347 Illustrations, many of which are in colors. Just Ready. 

Cloth, $3 50; Oil Cloth, 14. 00 

GORDINIER. Anatomy of the Central Nervous System. 
With 271 Illustrations, many of which are original. Just Ready. 

Cloth, $6.00; Sheep, $7.00 

HEATH. Practical Anatomy. 8th Edition. 300 Illus. $4.25 

HOLDEN. Anatomy. A Manual of the Dissections of the Human 
Body. Carefully Revised by A. Hewson, m.d., Demonstrator of 
Anatomy, Jefferson Medical College, Philadelphia. 311 Illustrations. 
7th Edition. In Press. 

HOLDEN. Human Osteology. Comprising a Description of the 
Bones, with Colored Delineations of the Attachments of the Muscles. 
The General and Microscopical Structure of Bone and its Develop- 
ment. With Lithographic Plates and numerous Illus. 8th Ed. $5.25 

HOLDEN. Landmarks. Medical and Surgical, ^th Ed. $1 00 

MACALISTER. Human Anatomy. Systematic and Topograph- 
ical, including the Embryology, Histology, and Morphology of Man. 
With Special Reference to the Requirements of Practical Surgery and 
Medicine. 816 Illustrations. Cloth, $5.00 ; Leather, $6.00 

MARSHALL. Physiological Diagrams. Life Size, Colored. 
Eleven Life-Size Diagrams (each seven feet by three feet seven 
inches). Designed for Demonstration before the Class. 

In Sheets, Unmounted, $40.00; Backed with Muslin and Mounted 
on Rollers, $60.00; Ditto, Spring Rollers, in Handsome Walnut Wall 
Map Case, $100.00; Single Plates — Sheets, $5.00 ; Mounted, $7.50. 
Explanatory Key, .50. Purchaser must pay Jreight charges. 

POTTER. Compend of Anatomy, Including Visceral Anatomy. 
6th Ed. 16 Lith. Plates and 117 other Illus. .80; Interleaved, $1.25 

WILSON. Human Anatomy, nth Edition. 429 Illustrations, 26 
Colored Plates, and a Glossary of Terms. $5.00 

WINDLE. Surface Anatomy. Colored and other Illus. $1.00 



SUBJECT CATALOGUE. 



BRAIN AND INSANITY. 

BLACKBURN. A Manual of Autopsies. Designed for the Use 
of Hospitals for the Insane and other Public Institutions. Ten full- 
page Plates and other Illustrations. $1.25 

GORDINIER. The Gross and Minute Anatomy of the Central 
Nervous System. With many full-page and other Illustrations. 
8vo. Just Ready. Cloth, #6.00; Sheep, $7.00 

GO WERS. Diagnosis of Diseases of the Brain. 2d Edition. 
Illustrated. $1.50 

HORSLEY. The Brain and Spinal Cord. The Structure and 
Functions of. Numerous Illustrations. $2.50 

LEWIS (BEVAN). Mental Diseases. A Text-Book Having 
Special Reference to the Pathological Aspects of Insanity. 26 Litho- 
graphic Plates and other Illustrations. 2d Ed. Just Ready. $7.00 

MANN. Manual of Psychological Medicine and Allied 
Nervous Diseases. Their Diagnosis, Pathology, Prognosis, and 
Treatment, including their Medico-Legal Aspects ; with chapter on 
Expert Testimony, and an Abstract of the Laws Relating to the 
Insane in all the States of the Union. Illustrated. %Z-°° 

REGIS. Mental Medicine. Authorized Translation by H. M. 
Bannister, m.d. $2.00 

STEARNS. Mental Diseases. Designed especially for Medical 
Students and General Practitioners. With a Digest of Laws of the 
various States Relating to Care of Insane. Illustrated. 

Cloth, $2.75; Sheep, #3.25 

TUKE. Dictionary of Psychological Medicine. Giving the 
Definition, Etymology, and Symptoms of the Terms used in Medical 
Psychology, with the Symptoms, Pathology, and Treatment of the 
Recognized Forms of Mental Disorders, together with the Law of 
Lunacy in Great Britain and Ireland. Two volumes. $10.00 

WOOD, H. C. Brain and Overwork. .40 

CHEMISTRY AND TECHNOLOGY. 

Special Catalogue of Chemical Books sent free upon application. 

ALLEN. Commercial Organic Analysis. A Treatise on the 
Modes of Assaying the Various Organic Chemicals and Products 
Employed in the Arts, Manufactures, Medicine, etc., with concise 
methods for the Detection of Impurities, Adulterations, etc. 8vo. 
Vol. I. Alcohols, Neutral Alcoholic Derivatives, etc , Ethers, Veg- 
etable Acids, Starch, Sugars, etc. 3d Edition, by Henry Leff- 

MANN, M. D. $4-50 

Vol. 11, Part I. Fixed Oils and Fats, Glycerol, Explosives, etc. 
3d Edition, by Henky Leffmann, m. d. Just Ready. $3 50 

Vol. II, P^rt II. Hydrocarbons, Mineral Oils, Phenols, etc. 3d 
Edition, by Henry Leffmann, m.d. Nearly Ready. 

Vol. Ill, Part I. Acid Derivatives of Phenols, Aromatic Acids, 
Tannins, Dyes and Coloring Matters. 3d Edition. Revised by 
J. Merritt Mathews, ph n., of the Philadelphia Textile School. 

In Preparation. 

Vol. Ill, Part II. The Amines, Hydrazines and Derivatives, 
Pyridine Bases. The Antipyretics, etc. Vegetable Alkaloids, Tea, 
Coffee, Cocoa, etc. 8vo. 2d Edition. $4 50 

Vol. Ill, Part III. Vegetable Alkaloids, Non- Basic Vegetable Bitter 
Principles. Animal Bases, Animal Acids, Cyanogen Compounds, 
etc. 2d Edition, 8vo. $4-5o 

Vol. IV. The Proteids and Albuminous Principles. 2d Edition. 
Just Ready. #4 .50 



MEDICAL BOOKS. 



ALLEN. Albuminous and Diabetic Urine. Illustrated. $2.25 
BARTLEY. Medical and Pharmaceutical Chemistry. A 

Text-Book for Medical, Dental, and Pharmaceutical Students. With 
Illustrations, Glossary, and Complete Index. 5th Edition, carefully 
Revised. Just Ready. Cloth, $3.00; Sheep, $3.50 

BARTLEY. Clinical Chemistry. The Examination of Feces, 
Saliva, Gastric Juice, Milk, and Urine. Just Ready. $1.00 

BLOXAM. Chemistry, Inorganic and Organic. With Experi- 
ments. 8th Ed., Revised 281 Engravings. Clo.,$4.25; Lea., $5.25 

CALDWELL. Elements of Qualitative and Quantitative 
Chemical Analysis. 3d Edition, Revised. $1.50 

CAMERON. Oils and Varnishes. With Illustrations. $2.25 

CAMERON. Soap and Candles. 54 Illustrations. $2.00 

GARDNER. The Brewer, Distiller, and Wine Manufac- 
turer. Illustrated. $i-5° 

GARDNER. Bleaching, Dyeing, and Calico Printing. $1.50 

GROVES AND THORP. Chemical Technology. The Appli- 
cation of Chemistry to the Arts and Manufactures. 
Vol. I. Fuel and Its Applications. 607 Illustrations and 4 Plates. 
Cloth, $5.00; Half Morocco, $6.50 
Vol.11. Lighting. Illustrated. Cloth, #4.00 ; Half Morocco, $5.50 
Vol.111. Lighting — Continued. In Press. 

HOLLAND. The Urine, the Gastric Contents, the Common 
Poisons, and the Milk. Memoranda, Chemical and Microscopi- 
cal, for Laboratory Use. 5th Ed. Illustrated and interleaved, $1.00 

LEFFMANN. Compend of Medical Chemistry, Inorganic 
and Organic. Including Urine Analysis. 4th Edition, Rewritten 
and Revised. .80; Interleaved, $1. 25 

LEFFMANN. Analysis of Milk and Milk Products. Arranged 
to Suit the Needs of Analytical Chemists, Dairymen, and Milk Inspec- 
tors. 2d Edition. Enlarged, Illustrated. $1.25 

LEFFMANN. Water Analysis. For Sanitary and Technic Pur- 
poses. Illustrated. 4th Edition. Just Ready. $1-25 

LEFFMANN. Structural Formulse. Including 180 Structural 
and Stereo-Chemical Formulae. i2mo. Interleaved. $1.00 

MUTER. Practical and Analytical Chemistry. 2d American 
from the Eighth English Edition. Revised to meet the requirements 
of American Medical Colleges by Claude C. Hamilton, m.d. 56 
Illustrations. $1.25 

OETTEL. Exercises in Electro-Chemistry. Illustrated. .75 

OETTEL. Electro-Chemical Experiments. Illustrated. .75 

RICHTER. Inorganic Chemistry. 4th American, from 6th Ger- 
man Edition. Authorized translation by Edgar F. Smith, m.a., 
ph.d. 89 Illustrations and a Colored Plate. $i-75 

RICHTER. Organic Chemistry. 3d American Edition. Trans, 
from the 8th German by Edgar F. Smith. Illustrated. 2 Volumes. 
Vol. I. Aliphatic Series. 625 Pages. Just Ready. $3.00 

Vol.11. Carbocylic Series. In Press. 

SMITH. Electro-Chemical Analysis. 2d Edition, Revised. 28 
Illustrations. $1-25 

SMITH AND KELLER. Experiments. Arranged for Students 
in General Chemistry. 3d Edition. Illustrated .60 

STAMMER. Chemical Problems. With Answers. .50 



SUBJECT CATALOGUE. 



SUTTON. Volumetric Analysis. A Systematic Handbook for 
the Quantitative Estimation of Chemical Substances by Measure, 
Applied to Liquids, Solids, and Gases. 7th Edition, Revised. 112 
Illustrations. $4-5° 

SYMONDS. Manual of Chemistry, for Medical Students. 
2d Edition. $2.00 

TRAUBE. Physico-Chemical Methods. Translated by Hardin. 
97 Illustrations. $1.50 

ULZER AND FRAENKEL. Chemical Technical Analysis. 
Translated by Fleck. Illustrated. $1-25 

WOODY. Essentials of Chemistry and Urinalysis. 4th 
Edition. Illustrated. In Press. 

*#* Special Catalogue of Books on Chemistry free upon application . 



CHILDREN. 

CAUTLIE. Feeding of Infants and Young Children by Nat- 
ural and Artificial Methods. $2.00 
HALE. On the Management of Children. .50 

HATFIELD. Compend of Diseases of Children. With a 
Colored Plate. 2d Edition. .80; Interleaved, $1. 25 

MEIGS. Infant Feeding and Milk Analysis. The Examination 
of Human and Cow's Milk, Cream, Condensed Milk, etc., and 
Directions as to the Diet of Young Infants. .50 

POWER. Surgical Diseases of Children and their Treat- 
ment by Modern Methods. Illustrated. #2-50 

STARR. The Digestive Organs in Childhood. The Diseases of 

the Digestive Organs in Infancy and Childhood. With Chapters on 
the Investigation of Disease and the Management of Children. 2d 
Edition, Enlarged. Illustrated by two Colored Plates and numerous 
Wood Engravings. $2.00 

STARR. Hygiene of the Nursery. Including the General Regi- 
men and Feeding of Infants and Children, and the Domestic Manage- 
ment of the Ordinary Emergencies of Early Life, Massage, etc. 6th 
Edition. 25 Illustrations. $1.00 

SMITH. Wasting Diseases of Children. 6th Edition. $2.00 
TAYLOR AND WELLS. The Diseases of Children. Illus- 
trated. A New Manual. 746 pages. Just Ready. $4.00 



CLINICAL CHARTS. 

GRIFFITH. Graphic Clinical Chart for Recording Temper- 
ature, Respiration, Pulse, Day of Disease, Date, Age, Sex, 
Occupation, Name, etc. Printed in three colors. Sample copie? 
free. Put up in loose packages of fifty, .50. Price to Hospitals, 500 
copies, $4.00; 1000 copies, $7.50. With name of Hospital printed 
on, .50 extra. 

KEEN'S CLINICAL CHARTS. Seven Outline Drawings of the 
Body, on which may be marked the Course of Disease, Fractures, 
Operations, etc. Pads of fifty, %\xo. Each Drawing may also be 
had separately, twenty-five to pad, 25 cents. 



MEDICAL BOOKS. 



SCHREINER. Diet Lists. Arranged in the form of a chart. 
Wiih Pamphlets of Specimen Dietaries. Pads of 50. .75 

DENTISTRY. 

Special Catalogue of Dental Books sent free upon application. 

BARRETT. Dental Surgery for General Practitioners and 
Students of Medicine and Dentistry. Extraction of Teeth, 
etc. 3d Edition. Illustrated. Nearly Ready. 

BLODGETT. Dental Pathology. By Albert N. Blodgett, 
m d., late Professor of Pathology and Therapeutics, Boston Dental 
College. 33 Illustrations. $1.25 

BROOMELL. Anatomy and Histology of the Human Mouth 
and Teeth. 284 Handsome Illustrations. $4-5° 

FLAGG. Plastics and Plastic Filling, as Pertaining to the Filling 
of Cavities in Teeth of all Grades of Structure. 4th Edition. #4.00 

FILLEBROWN. A Text-Book of Operative Dentistry. 

Written by invitation of the National Association of Dental Facul- 
ties. Illustrated. $2.25 
GORGAS. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. 6th Edition, Revised. Cloth, $4.00; Sheep, $5.00 

HARRIS. Principles and Practice of Dentistry. Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, 
and Mechanism. 13th Edition. Revised by F. J. S. Gorgas, m.d., 
d.d.s. 1250 Illustrations. Cloth, #6.00; Leather, $7.00 

HARRIS. Dictionary of Dentistry. Including Definitions of Such 
Words and Phrases of the Collateral Sciences as Pertain to the Art and 
Practice of Dentistry. 6th Edition. Revised and Enlarged by Fer- 
dinand F. S. Gorgas, m d., d.d.s. Cloth, #5.00 ; Leather, $6.00 

HEATH. Injuries and Diseases of the Jaws. 4th Edition. 187 

Illustrations. #4-5° 

HEATH. Lectures on Certain Diseases of the Jaws. 64 

Illustrations. Boards, .50 

RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- 
oughly Revised and Enlarged by Dr. Geo. W; Warren. 691 Illus- 
trations. Cloth, $$. 00; Leather, $6.00 

SEWELL. Dental Surgery. Including Special % Anatomy and 
Surgery. 3d Edition, with 200 Illustrations. #2.00 

SMITH. Dental Metallurgy. Illustrated. $1.75 

TAFT. Index of Dental Periodical Literature. #2.00 

TALBOT. Irregularities of the Teeth and Their Treatment. 

2d Edition. 234 Illustrations. I300 

TOMES. Dental Anatomy. Human and Comparative. 263 Illus- 
trations. 5th Edition. $4.00 
TOMES. Dental Surgery. 4th Edition. 289 Illustrations. $4.00 
WARREN. Compend of Dental Pathology and Dental Medi- 
cine. With a Chapter on Emergencies. 3d Edition. Illustrated. 

.80; Interleaved, #1.25 

WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25 
WHITE. The Mouth and Teeth. Illustrated. .40 

*#* Special Catalogue of Dental Books free upon application. 



SUBJECT CATALOGUE. 



DICTIONARIES. 

GOULD. The Illustrated Dictionary of Medicine, Biology, 
and Allied Sciences. Being an Exhaustive Lexicon of Medicine 
and those Sciences Collateral to it: Biology (Zoology and Botany), 
Chemistry, Dentistry, Parmacology, Microscopy, etc., with many 
useful Tables and numerous fine Illustrations. 1633 pages. 4th Ed. 
Sheep or Half Dark Green Leather, $10.00; Thumb Index, $11.00 
Half Russia, Thumb Index, #12.00 

GOULD. The Medical Student's Dictionary. Including all the 
Words and Phrases Generally Used in Medicine, with their Proper 
Pronunciation and Definition, Based on Recent Medical Literature. 
With Tables of the Bacilli, Micrococci, Mineral Springs, etc., of the 
Arteries, Muscles, Nerves, Ganglia, and Plexuses, etc. 10th Edition. 
Rewritten and Enlarged. Completely reset from new type. 700 pp. 
Half Dark Leather, $3.25 ; Half Morocco, Thumb Index, #4.00 

GOULD. The Pocket Pronouncing Medical Lexicon. 3d Edi- 
tion. (28,000 Medical Words Pronounced and Defined.) Containing 
all the Words, their Definition and Pronunciation, that the Medical, 
Dental, or Pharmaceutical Student Generally Comes in Contact 
With; also Elaborate Tables of the Arteries, Muscles, Nerves, 
Bacilli, etc., etc., a Dose List in both English and Metric Systems, 
etc., Arranged in a Most Convenient Form for Reference and Memor- 
izing. A new Edition from new type, enlarged by 225 pages. 
Just Ready. 

Full Limp Leather, Gilt Edges, $1.00 ; Thumb Index, $1.25 
90,000 Copies of Gould's Dictionaries Have Been Sold. 
*#* Sample Pages and Illustrations and Descriptive Circulars ot 

Gould's Dictionaries sent free upon application. 

HARRIS. Dictionary of Dentistry. Including Definitions of Such 
Words and Phrases of the Collateral Sciences as Pertain to the Art 
and Practice of Dentistry. 6th Edition. Revised and Enlarged by 
Ferdinand J. S. Gorgas, m.d., d.d.s. Cloth, $5.00; Leather, $6 00 

LONGLEY. Pocket Medical Dictionary. With an Appendix, 
containing Poisons and their Antidotes, Abbreviations used in Pre- 
scriptions, etc. Cloth, .75 ; Tucks and Pocket, $1.00 

MAXWELL. Terminologia Medica Polyglotta. By Dr. 
Theodore Maxwell, Assisted by Others. $3-oo 

The object of this work is to assist the medical men ot any nationality 

in reading medical literature written in a language not their own. 

Each term is us'ually given in seven languages, viz. : English, French, 

German, Italian, Spanish, Russian, and Latin. 

TREVES AND LANG. German-English Medical Dictionary. 

Half Russia, $3.25 

EAR (see also Throat and Nose). 

BURNETT. Hearing and How to Keep It. Illustrated. .40 

DALBY. Diseases and Injuries of the Ear. 4th Edition. 38 
Wood Engravings and 8 Colored Plates. $2.50 

HOVELL. Diseases of the Ear and Naso-Pharynx. Includ- 
ing Anatomy and Physiology of the Organ, together with the Treat- 
ment of the Affections of the Nose and Pharynx which Conduce to 
Aural Disease. 122 Illustrations. 2d Edition. Preparing. 

PRITCHARD. Diseases of the Ear. 3d Edition, Enlarged. 
Many Illustrations and Formulas. $i-5° 

WOAKES. Deafness, Giddiness, and Noises in the Head. 
4th Edition. Illustrated. $2.00 



MEDICAL BOOKS. 



ELECTRICITY. 

BIGELOW. Plain Talks on Medical Electricity and Bat- 
teries. With a Therapeutic Index and a Glossary. 43 Illustra- 
tions. 2d Edition. $ I -°o 

JONES. Medical Electricity. 3d Edition. 112 Illus. In Press. 

MASON. Electricity ; Its Medical and Surgical Uses. Numer- 
ous Illustrations. .75 

EYE. 

A Special Circular of Books on the Eye sent free upon application . 

ARLT. Diseases of the* Eye. Clinical Studies on Diseases of the 
Eye. Translation by Lyman Ware. m.d. Illustrated. $1-25 

DONDERS. The Nature and Consequences of Anomalies of 
Refraction. With Portrait and other Illustrations. 8vo. 

Just Ready. Half Morocco, $1 .25 

FICK. Diseases of the Eye and Ophthalmoscopy. Trans- 
lated by A. B. Hale, m. d. 157 Illustrations, many of which are in 
colors, and a glossary. Cloth, #4.50 ; Sheep, $5.50 

GOULD AND PYLE. Compend of Diseases of the Eye and 
Refraction. Including Treatment and Operations, and a Section 
on Local Therapeutics. With Formulae, Useful Tables, a Glossary, 
and in Illustrations, several of which are in colors. 

Cloth, .80; Interleaved, $1. 25 

GOWERS. Medical Ophthalmoscopy. A Manual and Atlas 
with Colored Autotype and Lithographic Plates and Wood-cuts, 
Comprising Original Illustrations of the Changes of the Eye in Dis- 
eases of the Brain, Kidney, etc. 3d Edition. $4.00 

HARLAN. Eyesight, and How to Care for It. Illus. .40 

HARTRIDGE. Refraction. 104 Illustrations and Test Types. 
9th Edition, Enlarged. #1.50 

HARTRIDGE. On the Ophthalmoscope. 3d Edition. With 
4 Colored Plates and 68 Wood-cuts. #1.50 

HANSELL AND REBER. Muscular Anomalies of the Eye. 
Illustrated. Just Ready. $ l -5° 

HANSELL AND BELL. Clinical Ophthalmology. Colored 
Plate of Normal Fundus and 120 Illustrations. $i-5o 

JESSOP. Manual of Ophthalmic Surgery and Medicine. Col- 
ored Plates and 108 other Illustrations. Just Ready. Cloth, $3 00 

MORTON. Refraction of the Eye. Its Diagnosis and the Cor- 
rection of its Errors. With Chapter on Keratoscopy and Test 
Types. 6th Edition. $1 00 

OHLEMANN. Ocular Therapeutics. Authorized Translation, 
and Edited by Dr. Charles A. Oliver. Just Ready. $ 1 -1S 

PHILLIPS. Spectacles and Eyeglasses. Their Prescription 
and Adjustment. 2d Edition. 49 Illustrations. $1.00 

SWANZY. Diseases of the Eye and Their Treatment. 6th 
Edition, Revised and Enlarged. 158 Illustrations, 1 Plain Plate, 
and a Zephyr Test Card. #3.00 

THORINGTON. Retinoscopy. 3d Edition. Illustrated. $1.00 

THORINGTON. Refraction and How to Refract. Illustrated. 

In Press 

WALKER. Students' Aid in Ophthalmology. Colored Plate 
and 40 other Illustrations and Glossary. $1.50 



10 SUBJECT CATALOGUE. 

FEVERS. 

COLLIE. On Fevers. Their History, Etiology, Diagnosis, Prog- 
nosis, and Treatment. Colored Plates. $2.00 

GOODALL AND WASHBOURN. Fevers and Their Treat- 
ment. Illustrated. $3-°o 

GOUT AND RHEUMATISM. 

DUCKWORTH. A Treatise on Gout. With Chromo-lithographs 
and Engravings. Cloth, $6.00 

GARROD. On Rheumatism. A Treatise on Rheumatism and 
Rheumatic Arthritis. Cloth, $5.00 

HAIG. Causation of Disease by Uric Acid. A Contribution to 
the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, 
Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. #3.00 

HEALTH AND DOMESTIC MEDI- 
CINE (see also Hygiene and Nursing). 

BUCKLEY. The Skin in Health and Disease. Illus. .40 

BURNETT. Hearing and How to Keep It. Illustrated. .40 

COHEN. The Throat and Voice. Illustrated .40 

DULLES. Emergencies. 4th Edition. Illustrated. $1.00 
HARLAN. Eyesight and How to Care for It. Illustrated. .40 

HARTSHORNE. Our Homes. Illustrated. .40 

OSGOOD. The Winter and its Dangers. .40 

PACKARD. Sea Air and Bathing. .40 

PARKES. The Elements of Health. $1.25 

RICHARDSON. Long Life and How to Reach It. .40 

WESTLAND. The Wife and Mother. $1.50 

WHITE. The Mouth and Teeth. Illustrated. .40 

WILSON. The Summer and its Diseases. .40 

■WOOD. Brain "Work and Overwork. .40 

STARR. Hygiene of the Nursery. 5th Edition. $1.00 

CANFIELD. Hygiene of the Sick-Room. $1.25 

HEART. 

SANSOM. Diseases of the Heart. The Diagnosis and Pathology 
of Diseases of the Heart and Thoracic Aorta. With Plates and other 
Illustrations. $6.00 

HISTOLOGY. 

STIRLING. Outlines of Practical Histology. 368 Illustrations. 
2d Edition, Revised and Enlarged. With new Illustrations. $2.00 

STOHR. Histology and Microscopical Anatomy. Translated 
and Edited by A. Schaper, m.d., Harvard Medical School. Second 
Edition, Revised and Enlarged. 292 Illustrations. $3-°° 



MEDICAL BOOKS. 



HYGIENE AND WATER ANALYSIS. 

Special Catalogue of Books on Hygiene sent free upon application. 

CANFIELD. Hygiene of the Sick-Room. A Book for Nurses 
and Others. Being a Brief Consideration of Asepsis, Antisepsis, Dis- 
infection, Bacteriology, Immunity, Heating, Ventilation, etc. $1.25 

COPLIN AND BEVAN, Practical Hygiene. A Complete 
American Text-Book. 138 Illustrations. New Ed. Preparing. 

KENWOOD. Public Health Laboratory Work. 116 Illustra- 
tions and 3 Plates. $2.00 

LEFFMANN. Examination of Water for Sanitary and 
Technical Purposes. 4th Edition. Illustrated. Just Ready. $1.25 

LEFFMANN. Analysis of Milk and Milk Products. Illus- 
trated. Second Edition. $ r -25 

LINCOLN. School and Industrial Hygiene. .40 

MACDONALD. Microscopical Examinations of Water and 
Air. 25 Lithographic Plates, Keference Tables, etc. 2d Ed. $2.50 

McNEILL. The Prevention of Epidemics and the Construc- 
tion and Management of Isolation Hospitals. Numerous Plans 
and Illustrations. $3-5o 

NOTTER AND FIRTH. The Theory and Practice of Hygiene. 
(Being the 9th Edition of Parkes' Practical Hygiene, rewritten and 
brought up to date.) 10 Plates and 135 other Illustrations. 1034 
pages. 8vo. $7.00 

PARKES. Hygiene and Public Health. By Louis C. Parkes, 
m.d. 5th Edition. Enlarged. Illustrated. $2.50 

PARKES. Popular Hygiene. The Elements of Health. A Book 
for Lay Readers. Illustrated. $1.25 

STARR. The Hygiene of the Nursery. Including the General 
Regimen and Feeding of Infants and Children, and the Domestic 
Management of the Ordinary Emergencies of Early Life, Massage, 
etc. 6th Edition. 25 Illustrations. #1.00 

STEVENSON AND MURPHY. A Treatise on Hygiene. By 
Various Authors. In Three Octave Volumes. Illustrated. 

Vol. I, $6.00; Vol. II, $6.00; Vol. Ill, $5.00 
*** Each Volume sold separately. Special Circular upon application. 

WILSON. Hand-Book of Hygiene and Sanitary Science. 

With Illustrations. 8th Edition. $300 

WEYL. Sanitary Relations of the Coal-Tar Colors. Author- ■ 
ized Translation by Henry Leffmann, m.d., ph.d. $1.25 

*#* Special Catalogue of Books on Hygiene free upon application. 

LUNGS AND PLEURA. 

HARRIS AND BEALE. Treatment of Pulmonary Consump- 
tion. $2.50 

KNOPF. Pulmonary Tuberculosis. Its Msdern Prophylaxis 
and Treatment in Special Inst : tutions and at Home. Illus. $3 00 

POWELL. Diseases of the Lungs and Pleurae, including 
Consumption. Colored Plates and other Illus. 4th Ed. $4.00 

TUSSEY. High Altitudes in the Treatment of Consumption. 

$1.50 



SUBJECT CATALOGUE. 



MASSAGE. 

KLEEN. Hand-Book of Massage. Authorized translation by 
Mussey Hartwell, m.d., ph.d. With an Introduction by Dr. S. 
Weir Mitchell. Illustrated by a series of Photographs Made 
Especially by Dr. Kleen for the American Edition. £2.25 

MURRELL. Massotherapeutics. Massage as a Mode of Treat- 
ment. 6th Edition. In Press. 

OSTROM. Massage and the Original Swedish Move- 
ments. Their Application to Various Diseases of the Body. A 
Manual for Students, Nurses, and Physicians. Fourth Edition, En- 
larged. 105 Illustrations, many of which are original. $1.00 

WARD. Notes on Massage. Interleaved. Paper cover, $1. 00 

MATERIA MEDICA AND THERA- 
PEUTICS. 

ALLEN, HARLAN, HARTE, VAN HARLINGEN. A 
Hand-Book of Local Therapeutics, Beinga Practical Description 
of all those Agents Used in the Local Treatment of Diseases of the 
Eye, Ear, Nose and Throat, Mouth, Skin, Vagina, Rectum, etc., 
such as Ointments, Plasters, Powders, Lotions, Inhalations, Supposi- 
tories, Bougies, Tampons, and the Proper Methods of Preparing and 
Applying Them. Cloth, #3.00 ; Sheep, $4.00 

BIDDLE. Materia Medica and Therapeutics. Including Dose 
List, Dietary for the Sick, Table of Parasites, and Memoranda of 
New Remedies. 13th Edition, Thoroughly Revised in accord- 
ance with the new U. S. P. 64 Illustrations and a Clinical Index. 

Cloth, $4.00 ; Sheep, $5.00 
BRACKEN. Outlines of Materia Medica and Pharmacology. $2.75 
COBLENTZ. The Newer Remedies. 3d Edition, Enlarged ar.d 
Revised. Just Ready. $1.00 

DAVIS. Materia Medica and Prescription Writing. ^1.50 
FIELD. Evacuant Medication. Cathartics and Emetics. $1.75 
GORGAS. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. 6th Edition, Revised. $4.00 

GROFF. Materia Medica for Nurses. $1.25 

HELLER. Essentials of Materia Medica, Pharmacy, and 
Prescription Writing. $1.50 

MAYS. Theine in the Treatment of Neuralgia. y 2 bound, .50 
NAPHEYS. Modern Therapeutics, qth Revised Edition, En- 
larged and Improved. In two handsome volumes. Edited by Allen 
J. Smith, m.d., and J. Aubrey Davis, m.d. 

Vol. I. General Medicine and Diseases of Children. $4.00 

Vol. II. General Surgery, Obstetrics, and Diseases of Women. $4.00 
POTTER. Hand-Book of Materia Medica, Pharmacy, and 
Therapeutics, including the Action of Medicines, Special Therapeu- 
tics, Pharmacology, etc., including over 600 Prescriptions and For- 
mula. 7th Edition, Revised and Enlarged. With Thumb Index in 
each copy, /ust Ready. Cloth, $5.00; Sheep, $6. co 

POTTER. Compend of Materia Medica, Therapeutics, and 
Prescription Writing, with Special Reference to the Physiologi- 
cal Action of Drugs. 6ih Revised and Improved Edition, based upon 
the U. S. P. 1890. .80; Interleaved, $1.25 



MEDICAL BOOKS. 13 



SAYRE. Organic Materia Medica and Pharmacognosy. An 

Introduction to the Study of the Vegetable Kingdom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics, Source, Constituents, and Pharmacopeial Prepara- 
tions. With chapters on Synthetic Organic Remedies, Insects In- 
jurious to Drugs, and Pharmacal Botany. A Glossary and 543 Illus- 
trations, many of which are original. 2d Edition. In Press. 

WARING. Practical Therapeutics. 4th Edition, Revised and 
Rearranged. Cloth, #2.00; Leather, $3.00 

WHITE AND WILCOX. Materia Medica, Pharmacy, Phar- 
macology, and Therapeutics. 4th American Edition, Revised by 
Reynold W. Wilcox, m.a., m.d., ll.d. Clo., $3.00; Lea., #3.50 



MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

REESE. Medical Jurisprudence and Toxicology. A Text-Book 
for Medical and Legal Practitioners and Students. 5th Edition. 
Revised by Henry Leffmann, m.d. Clo., $3.00; Leather, $3.50 

" To the student of medical jurisprudence and toxicology it is in- 
valuable, as it is concise, clear, and thorough in every respect." — The 
American Journal of the Medical Sciences. 

MANN. Forensic Medicine and Toxicology. Illus. $6.50 

MURRELL. What to Do in Cases of Poisoning. 8th 

Edition, Enlarged. $1.00 

TANNER. Memoranda of Poisons. Their Antidotes and Tests. 
7th Edition. .75 



MICROSCOPY. 

BEALE. The Use of the Microscope in Practical Medicine. 
For Students and Practitioners, with Full Directions for Examining the 
Various Secretions, etc., by the Microscope. 4th Ed. 500 Illus. #6.50 

BEALE. How to Work with the Microscope. A Complete 
Manual of Microscopical Manipulation, containing a Full Description 
of many New Processes of Investigation, with Directions for Examin- 
ing Objects Under the Highest Powers, and for Taking Photographs 
of Microscopic Objects. 5th Edition. 400 Illustrations, many of 
them colored. $6.50 

CARPENTER. The Microscope and Its Revelations. 8th 

Edition. 800 Illustrations and many Lithographs. Preparing : 

LEE. The Microtomist's Vade Mecum. A Hand-Book of 
Methods of Microscopical Anatomy. 887 Articles. 4th Edition, 
Enlarged. #4.00 

REEVES. Medical Microscopy, including Chapters on Bacterid 
ology, Neoplasms, Urinary Examination, etc. Numerous Illus • 
trations, some of which are printed in colors. $2.50 

WETHERED. Medical Microscopy. A Guide to the Use of the 
Microscope in Practical Medicine. 100 Illustrations. $2.00 



14 SUBJECT CATALOGUE. 

MISCELLANEOUS. 

BLACK. Micro-Organisms. The Formation of Poisons. A 
Biological Study of the Germ Theory of Disease. .75 

BRAMWELL. Anaemia. Just Ready. $2.50 

BURNETT. Foods and Dietaries. A Manual of Clinical Diet- 
etics. 2d Edition. $1.50 
BUXTON. Anaesthetics. Illustrated. 3d Edition. In Press. 
GOULD. Borderland Studies. Miscellaneous Addresses and 
Essays. i2mo. $2.00 
GOWERS. The Dynamics of Life. .75 
HAIG. Causation of Disease by Uric Acid. A Contribution to 
the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, 
Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. $3.00 
HAIG. Diet and Food. Considered in Relation to Strength and 
Power of Endurance. Just Ready. $1.00 
HARE. Mediastinal Disease. Illustrated by six Plates. $2.00 
HEMMETER. Diseases of the Stomach. Their Special Path- 
ology, Diagnosis, and Treatment. With Sections on Anatomy, Diet- 
etics, Surgery, etc. Illustrated. Clo. $6.00; Sh. $7.00 
HENRY. A Practical Treatise on Anemia. Half Cloth, .50 
LEFFMANN. The Coal-Tar Colors. With Special Reference to 
their Injurious Qualities and the Restrictions of their Use. A Trans- 
lation of Theodore Weyl's Monograph. #1.25 
MARSHALL. History of Woman's Medical College of Penn- 
sylvania. $1-50 
NEW SYDENHAM SOCIETY'S PUBLICATIONS. Circulars 
upon application. Per Annum, $8. go 
TREVES. Physical Education : Its Effects, Methods, Etc. .75 
LIZARS. The Use and Abuse of Tobacco. .40 
PARRISH. Alcoholic Inebriety. $1.00 
ST. CLAIR. Medical Latin. $1.00 
SCHREINER. Diet Lists. Pads of 50. .75 
TURNBULL. Artificial Anaesthesia. 4th Edition. Illus. $2.50 

NERVOUS DISEASES. 

BEEVOR. Diseases of the Nervous System and their Treat- 
ment. $2.50 

GORDINIER. The Gross and Minute Anatomy of the Cen- 
tral Nervous System. With 271 original Colored and other 
Illustrations. Just Ready. Cloth, $6 co; Sheep, $7.00 

GOWERS. Manual of Diseases of the Nervous System. A 
Complete Text-Book. Revised, Enlarged, and in many parts Re- 
written. With many new Illustrations. Two volumes. 
Vol. I. Diseases of the Nerves and Spinal Cord. 3d Edition, En- 
larged. Just Ready. Cloth, $4.00; Sheep, $5.00 
Vol. II. Diseases of the Brain and Cranial Nerves; General and 
Functional Disease. 2d Edition. Cloth, $4.00; Sheep, $5.00 

GOWERS. Syphilis and the Nervous System. $1,00 

GOWERS. Diagnosis of Diseases of the Brain. 2d Edition. 
Illustrated. $1.50 

GOWERS. Clinical Lectures. A New Volume of Essays on the 
Diagnosis, Treatment, etc., of Diseases of the Nervous System. $2.00 

GOWERS. Epilepsy and Other Chronic Convulsive Diseases. 
2d Edition. In Press. 



MEDICAL BOOKS. 15 



HORSLEY. The Brain and Spinal Cord. The Structure and 
Functions of. Numerous Illustrations. $2.50 

ORMEROD. Diseases of the Nervous System. 66 Wood En- 
gravings. #1.00 

OSLER. Cerebral Palsies of Children. A Clinical Study. $2.00 

OSLER. Chorea and Choreiform Affections. $2.00 

PRESTON. Hysteria and Certain Allied Conditions. Their 
Nature and Treatment. Illustrated. $2.00 

WATSON. Concussions. An Experimental Study of Lesions Aris- 
ing from Severe Concussions. Paper cover, $1.00 

WOOD. Brain Work and Overwork. .40 

NURSING. 

Special Catalogue of Books for Nurses sent free upon application. 

BROWN. Elementary Physiology for Nurses. .75 

CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and 
Others. Being a Briet Consideration of Asepsis, Antisepsis, Disinfec- 
tion, Bacteriology, Immunity, Heating and Ventilation, and Kindred 
Subjects for the Use of Nurses and Other Intelligent Women. $1.25 

CULLINGWORTH. A Manual of Nursing, Medical and Sur- 
gical. 3d Edition with Illustrations. .75 

CULLINGWORTH. A Manual for Monthly Nurses. 3d Ed. .40 

CUFF. Lectures to Nurses on Medicine. New Ed. $1.25 

DOMVILLE. Manual for Nurses and Others Engaged in At- 
tending the Sick. 8th Edition. With Recipes for Sick-room Cook- 
ery, etc. .75 

FULLERTON, Obstetric Nursing. 41 Ills. 5th Ed. $1.00 

FULLERTON. Surgical Nursing. Comprising the Regular 
Course of Instruction at the Training-School of the Woman's Hos- 
pital, Philadelphia. 3d Edition. 6j Illustrations. $i.co 

GROFF. Materia Medica for Nurses. With Questions for Self-Ex- 
amination and a very complete Glossary. $ x - 2 5 

HUMPHREY. A Manual for Nurses. Including General 
Anatomy and Physiology, Management of the Sick Room, etc. 
16th Ed. Illustrated. $1.00 

SH AWE. Notes for Visiting Nurses, and all those Interested 
in the Working and Organization of District, Visiting, or 
Parochial Nurse Societies. With an Appendix Explaining the 
Organization and Working of Various Visiting and District Nurse So- 
cieties, by Helen C. Jenks, of Philadelphia. $1.00 

STARR. The Hygiene of the Nursery. Including the General 
Regimen and Feeding of Infants and Children, and the Domestic Man- 
agement of the Ordinary Emergencies of Early Life, Massage, etc. 6th 
Edition. 25 Illustrations. #1.00 

TEMPERATURE AND CLINICAL CHARTS. See page 6. 

VOSWINKEL. Surgical Nursing. Second Edition, Enlarged. 
112 Illustrations. Just Ready. $1.00 

WARD. Notes on Massage. Interleaved. Paper cover, $1.00 

OBSTETRICS. 

BAR. Antiseptic Midwifery. The Principles of Antiseptic Meth- 
ods Applied to Obstetric Practice. Authorized Translation by 
Henry D Fry, m.d., with an Appendix by the Author. #1.00 



16 SUBJECT CATALOGUE. 

CAZEAUX AND TARNIER. Midwifery. With Appendix by 
Mundb. The Theory and Practice of Obstetrics, including the Dis- 
eases ot Pregnancy and Parturition, Obstetrical Operations, etc. 
8th Edition. Illustrated by Chromo- Lithographs, Lithographs, and 
other full-page Plates, seven of which are beautifully colored, and 
numerous Wood Engravings. Cloth, $4.50 ; Full Leather, $5.50 

DAVIS. A Manual of Obstetrics. Being a Complete Manual for 
Physicians and Students. 3d Enlarged and Revised Edition. With 
Colored and many other Illustrations. In Press. 

LANDIS. Compend of Obstetrics. 6th Edition, Revised by Wm. 
H. Wells, Assistant Demonstrator of Clinical Obstetrics, Jefferson 
Medical College. With 47 Illustrations, .80; Interleaved, $1.25. 

SCHULTZE. Obstetrical Diagrams. Being a series of 20 Col- 
ored Lithograph Charts, Imperial Map Size, of Pregnancy and Mid- 
wifery, with accompanying explanatory (German) text illustrated 
by Wood Cuts. 2d Revised Edition. 

Price in Sheets, $26.00 ; Mounted on Rollers, Muslin Backs, $36. 00 

STRAHAN. Extra-Uterine Pregnancy. The Diagnosis and 
Treatment of Extra-Uterine Pregnancy. .75 

WINCKEL. Text-Book of Obstetrics, Including the Pathol- 
ogy and Therapeutics of the Puerperal State. Authorized 
Translation by J. Clifton Edgar, a.m., m.d. With nearly 200 Illus- 
trations. Cloth, $5.00 ; Leather, $6.00 

FULLERTON. Obstetric Nursing. 5th Ed. Illustrated. $1.00 

PATHOLOGY. 

BARLOW. General Pathology. 795 pages. 8vo. $5.00 

BLACKBURN. Autopsies. A Manual of Autopsies Designed for 
the Use ot Hospitals for the Insane and other Public Institutions. 
Ten full-page Plates and other Illustrations. $125 

BLODGETT. Dental Pathology. By Albert N. Blodgett, 
m.d., late Professor of Pathology and Therapeutics, Boston Dental 
College. 33 Illustrations. $ x -25 

COPLIN. Manual of Pathology. Including Bacteriology, Technic 
of Post-Mortems, Methods of Pathologic Research, etc. 275 Illus- 
trations, many of which are original. 3d. Edition. Nearly Ready. 

GILLIAM. Pathology. A Hand-Book for Students. 47 lllus. .75 

HALL. Compend of General Pathology and Morbid Anatomy. 
91 very fine Illustrations. 2d Edition. .80: Interleaved, $1.25 

HEWLETT. Manual of Bacteriology. 75 Illustrations. $3.00 

VIRCHOW. Post-Mortem Examinations. A Description and 
Explanation of the Method of Performing Them in the Dead House 
of the Berlin Charity Hospital, with Special Reference to Medico- 
Leeal Practice. 3d Edition, with Additions. .75 

WHITACRE. Laboratory Text-Book of Pathology. With 
T2i Illustrations. $150 

WILLIAMS. Bacteriology. A Manual for Students. 78 Illus- 
trations. $1.50 

PHARMACY. 

Special Catalogue of Books on Pharmacy sent free upon application. 

COBLENTZ. The Newer Remedies. Including their Synonyms, 
Sources, Methods of Preparation, Tests, Solubilities, and Doses as 
far as known. Together with Sections on the Organo-Therapeutic 
Agents and Indifferent Compounds of Iron. Third Edition, very 
much Enlarged. Just Ready. #1.00 

COBLENTZ. Manual of Pharmacy. A New and Complete 
Text-Book by the Professor in the New York College of Pharmacy. 
2d Edition, Revised and Enlarged. 437 lllus. Cloth, $3.50; Sh., $4 50 



MEDICAL BOOKS. 



BEASL-EY. Book of 3100 Prescriptions. Collected from the 
Practice of the Most Eminent Physicians and Surgeons — English, 
French, and American. A Compendious History ot the Materia 
Medica, Lists of the Doses of all the Officinal and Established Pre- 
parations, an Index of Diseases and their Remedies. 7th Ed. $2.00 

BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprietary 
Medicines, Druggists' Nostrums, etc. ; Perfumery and Cosmetics, 
Beverages, Dietetic Articles and Condiments, Trade Chemicals, 
Scientific Processes, and many Useful Tables. 10th Ed. $2.00 

BEASLEY. Pharmaceutical Formulary. A Synopsis of the 
British, French, German, and United States Pharmacopoeias. Com- 
prising Standard and Approved Formulae for the Preparations and 
Compounds Employed in Medicine. 12th Edition. Just Ready. $2.00 

PROCTOR. Practical Pharmacy. Lectures on Practical Phar- 
macy. With Wood Engravings and 32 Lithographic Fac-simile 
Prescriptions. 3d Edition, Revised, and with Elaborate Tables of 
Chemical Solubilities, etc. $3.00 

ROBINSON. Latin Grammar of Pharmacy and Medicine. 
3d Edition. With elaborate Vocabularies. $1 .75 

SAYRE. Organic Materia Medica and Pharmacognosy. An 
Introduction to the Study of the Vegetable Kinedom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics, Source, Constituents, and Pharmacopeial Prepar- 
ations. With Chapters on Synthetic Organic Remedies, Insects 
Injurious to Drugs, and Pharmacal Botany. A Glossary and 543 
Illustrations. Second Edition. In Press. 

SCOVILLE. The Art of Compounding. Second Edition, Re- 
vised and Enlarged. Cloth, $2.50; Sheep, #3.50 

STEWART. Compend of Pharmacy. Based upon " Reming- 
ton's Text-Book of Pharmacy." 5th Edition, Revised in Accord- 
ance with the U. S. Pharmacopoeia, 1890. Complete Tables of 
Metric and English Weights and Measures. .80; Interleaved, $1.25 

UNITED STATES PHARMACOPOEIA. 1890. 7 th Decennial 
Revision. Cloth, $2.50 (postpaid, $2.77); Sheep, $3.00 (postpaid, 
$3.27); Interleaved, $4.00 (postpaid, $4.50); Printed on one side ot 
page only, unbound, $3.50 (postpaid, $3.90). 

Select Tables from the U. S. P. (1890). Being Nine of the Most 
Important and Useful Tables, Printed on Separate Sheets. Care- 
fully put up in patent envelope. .25 

POTTER. Hand-Book of Materia Medica, Pharmacy, and 
Therapeutics. 600 Prescriptions. 7th Ed. Clo.,$5-oo; Sh., $6.00 

*** Special Catalogue 0/ Books on Pharmacy free upon application, 

PHYSICAL DIAGNOSIS. 

BROWN. Medical Diagnosis. A Manual of Clinical Methods. 
4th Edition. 112 Illustrations. Cloth, $2. 25 

FENWICK. Medical Diagnosis. 8th Edition. Rewritten and 
very much Enlarged. 135 Illustrations. Cloth, $2.50 

MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $1 00 

TYSON. Hand-Book of Physical Diagnosis. For Students and 
Physicians. By the Professor of Clinical Medicine in the University 
of Pennsylvania.' Illus. 3d Ed., Improved and Enlarged. With 
Colored and other Illustrations. $*-5° 

2 



SUBJECT CATALOGUE. 



PHYSIOLOGY. 

BIRCH. Practical Physiology. An Elementary Class Book. 
62 llhrstr Uions Just Ready. $f-75 

BRUBAKER. Compend of Physiology. 9th Edition, Revised 
and Enlarged. Illustrated. Just Ready. .80; Interleaved, $1.25 

KIRKE. Physiology. (15th Authorized Edition. Dark-Red Cloth.) 
A Hand-Book of Physiology. 15th Edition, Revised, Rearranged, 
and Enlarged. By Prof. W. D. Halliburton, of Kings College, 
London. 661 Illustrations, some of which are printed in colors. 
Just Ready. Cloth, $3.00; Leather, $3.75 

LANDOIS. A Text-Book of Human Physiology, Including 
Histology and Microscopical Anatomy, with Special Reference to 
the Requirements of Practical Medicine. 5th American, translated 
from the 9th German Edition, with Additions by Wm. Stirling, 
m.d.,d.sc. 845 Illus., many of which are printed in colors. In Press. 

STARLING. Elements of Human Physiology. 100 Ills. $1.00 

STIRLING. Outlines of Practical Physiology. Including 
Chemical and Experimental Physiology, with Special Reference to 
Practical Medicine. 3d Edition. 289 Illustrations. $2.00 

TYSON. Cell Doctrine. Its History and Present State. $1.50 

PRACTICE. 

BEALE. On Slight Ailments; their Nature and Treatment. 

2d Edition, Enlarged and Illustrated. #1.25 

FOWLER. Dictionary of Practical Medicine. By various 

writers. An Encyclopaedia of Medicine. Clo.,$3.oo; Half Mor. $4.00 

HUGHES. Compend of the Practice of Medicine. 6th Edition, 

Revised and Enlarged. Just Ready. 

Part I. Continued, Eruptive, and Periodical Fevers, Diseases of the 
Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kid- 
neys, etc., and General Diseases, etc. 
Part II. Diseases of the Respiratory System, Circulatory System, 
and Nervous System; Diseases of the Blood, etc. 

Price of each part, .80; Interleaved, $1.25 
Physician's Edition. In one volume, including the above two 
parts, a Section on Skin Diseases, and an Index. 6th Revised, 
Enlarged Edition. 575 pp. Full Morocco, Gilt Edge, $2.25 

ROBERTS. The Theory and Practice of Medicine. The 
Sections on Treatment are especially exhaustive. 9th Edition, 
with Illustrations. Cloth, $4.50 ; Leather, $5.50 

TAYLOR. Practice of Medicine. 5th Edition. Cloth, $4.00 

TYSON. The Practice of Medicine. By James Tyson, m.d., 
Professor of Clinical Medicine in the University of Pennsylvania. 
A Complete Systematic Text-book with Special Reference to Diag- 
nosis and Treatment. Illustrated. 8vo. 

Cloth, $5.50 ; Leather, $6.50; Half Russia, $7.50 

PRESCRIPTION BOOKS. 

BEASLEY. Book of 3100 Prescriptions. Collected from the 
Practice of the Most Eminent Physicians and Surgeons — English, 
French, and American. A Compendious History of the Materia, 
Medica, Lists of the Doses of all Officinal and Established Prepara- 
tions, and an Index of Diseases and their Remedies. 7th Ed. #2.00 



MEDICAL BOOKS. 19 



BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprie- 
tary Medicines, Druggists' Nostrums, etc. ; Perfumery and Cos- 
metics, Beverages, Dietetic Articles and Condiments, Trade Chem- 
icals, Scientific Processes, and an Appendix of Useful Tables, 
ioth Edition, Revised. $2.00 

BEASLEY. Pocket Formulary. A Synopsis of the British, French, 
German, and United States Pharmacopoeias and the chief unofficial 
Formularies. 12th Edition. Just Ready. $2.00 

SKIN. 

BULKLEY. The Skin in Health and Disease. Illustrated. .40 
CROCKER. Diseases of the Skin. Their Description, Pathol- 
ogy, Diagnosis, and Treatment, with Special Reference to the Skin 
Eruptions of Children. 92 Illus. 3d Edition. Preparing. 

IMPEY. Leprosy. 37 Plates. 8vo. $3.50 

SCHAMBERG. Diseases of the Skin. 99 Illustrations. Being 
No. 16? Quiz-Compend? Series. Cloth, .80; Interleaved, $1.25 

VAN HARLINGEN. On Skin Diseases. A Practical Manual 
of Diagnosis and Treatment, with special reference to Differential 
Diagnosis. 3d Edition, Revised and Enlarged. With Formulae 
and 60 Illustrations, some of which are printed in colors. $2.75 

SURGERY AND SURGICAL DIS- 
EASES (see also Urinary Organs). 

CRIPPS. Ovariotomy and Abdominal Surgery. Illus. $8.00 

DEAVER. Surgical Anatomy. A Treatise on Human Anatomy 
in its Application to Medicine and Surgery. With about 400 very 
Handsome full-page Illustrations Engraved from Original Drawings 
made by special Artists from Dissections prepared for the purpose. 
Three Volumes. Royal Square Octavo. Volume I, Just Ready. 
Cloth, $21.00; Half Morocco or Sheep, $24.00 ; Half Russia, $27.00 

DEAVER. Appendicitis, Its Symptoms, Diagnosis, Pathol- 
ogy, Treatment, and Complications. Elaborately Illustrated 
with Colored Plates and other Illustrations. Cloth, $3.50 

DULLES. "What to Do First in Accidents and Poisoning. 
5th Edition. New Illustrations. $1.00 

HACKER. Antiseptic Treatment of Wounds, According to 
the Method in Use at Professor Billroth's Clinic, Vienna. .50 

HAMILTON. Lectures on Tumors, from a Clinical Stand- 
point. Third Edition, Revised, with New Illustrations. $1.25 

HEATH. Minor Surgery and Bandaging, ioth Ed., Revised 
and Enlarged. 158 Illustrations, 62 Formulae, Diet List, etc. $1.25 

HEATH. Injuries and Diseases of the Jaws. 4th Edition. 
187 Illustrations. $4-5o 

HEATH. Lectures on Certain Diseases of the Jaws. 64 Illus- 
trations. Boards, .50 

HORW1TZ. Compend of Surgery and Bandaging, including 
Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- 
eases, and the Latest Antiseptic Rules, etc., with Differential Diagno- 
sis and Treatment. 5th Edition, very much Enlarged and Rear- 
ranged. 167 Illustrations, 98 Formulae. Clo., .80 ; Interleaved, $1.25 



20 SUBJECT CATALOGUE. 

JACOBSON. Operations of Surgery. Over 200 Illustrations. 

Cloth, $3.00; Leather, $4.00 
JACOBSON. Diseases of the Male Organs of Generation. 

88 Illustrations. $6.00 

LANE. Surgery of the Head and Neck, no Illustrations. 
2d Edition. Just Ready. $5-oo 

MACREADY. A Treatise on Ruptures. 24 Full-page Litho- 
graphed Plates and Numerous Wood Engravings. Cloth, $6.00 
MAYLARD. Surgery of the Alimentary Canal. 134 lllus. $7.50 

MOULLIN. Text-Book of Surgery. With Special Reference to 
Treatment. 3d American Edition. Revised and edited by John B. 
Hamilton, m.d., ll.d., Professor of the Principles of Surgery and 
Clinical Surgery, Rush Medical College, Chicago. 623 Illustrations, 
over 200 of which are original, and many of which are printed in 
colors. Handsome Cloth, $6.00; Leather, $7.00 

" The aim to make this valuable treatise practical by giving special 

attention to questions of treatment has been admirably carried out. 

Many a reader will consult the work with a feeling of satisfaction that 

his wants have been understood, and that they have been intelligently 

met." — The American Journal of Medical Science. 

ROBERTS. Fractures of the Radius. A Clinical and Patho- 
logical Study. 33 Illustrations. $1.00 

SMITH. Abdominal Surgery. Being a Systematic Description ot 
all the Principal Operations. 224 lllus. 6th Ed. 2 Vols. Clo., $10.00 

SWAIN. Surgical Emergencies. Fifth Edition. Cloth, $1. 75 

VOSWINKEL. Surgical Nursing. Second Edition, Revised and 
Enlarged, in Illustrations, fust Ready. $1.00 

WALSHAM. Manual of Practical Surgery. 6th Ed., Re- 
vised and Enlarged. With 410 Engravings. $3-oo 

WATSON. On Amputations of the Extremities and Their 
Complications. 250 Illustrations. $5-5o 

THROAT AND NOSE (see also Ear). 

COHEN. The Throat and Voice. Illustrated. .40 

HALL. Diseases of the Nose and Throat. Two Colored 

Plates and 59 Illustrations. $2.50 

HOLLOPETER. Hay Fever. Its Successful Treatment. $1.00 

HUTCHINSON. The Nose and Throat. Including the Nose, 

Naso-Pharynx, Pharynx, and Larynx. Illustrated by Lithograph 

Plates and 40 other Illustrations. 2d Edition. In Press. 

MACKENZIE. Pharmacopoeia of the London Hospital for 
Dis. of the Throat. 5th Ed., Revised by Dr. F. G. Harvey. $1.00 

McBRIDE. Diseases of the Throat, Nose, and Ear. A Clinical 
Manual. With colored lllus. from original drawings. 2d Ed. $6.00 

POTTER. Speech and its Defects. Considered Physiologically, 
Pathologically, and Remedially. $1.00 

URINE AND URINARY ORGANS. 

ACTON. The Functions and Disorders of the Reproductive 
Organs in Childhood, Youth, Adult Age, and Advanced Life, 
Considered in their Physiological, Social, and Moral Relations. 
8th Edition. $1.75 



MEDICAL BOOKS. 21 



ALLEN. Albuminous and Diabetic Urine. Illus. $2.25 

BEALE. One Hundred Urinary Deposits. On eight sheets, 
for the Hospital, Laboratory, or Surgery. Paper, $2.00 

HOLLAND. The Urine, the Gastric Contents, the Common 
Poisons, and the Milk. Memoranda, Chemical and Microscopi- 
cal, for Laboratory Use. Illustrated and Interleaved. 5th Ed. #1.00 

JACOBSON. Diseases of the Male Organs of Generation. 88 
Illustrations $6.00 

MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $1.00 

MORRIS. Renal Surgery, with Special Reference to Stone in the 
Kidney and Ureter and to the Surgical Treatment of Calculous 
Anuria. Illustrated. $2.00. 

MOULLIN. Enlargement of the Prostate. Its Treatment and 
Radical Cure. 2d Edition. Illustrated. In Press. 

MOULLIN. Inflammation of the Bladder and Urinary Fever. 
Octavo. Just Ready. $1.50 

THOMPSON. Diseases of the Urinary Organs. 8th Ed. $3.00 

TYSON. Guide to Examination of the Urine. For the Use of 
Physicians and Students. With Colored Plate and Numerous Illus- 
trations engraved on wood. 9th Edition, Revised. $1-25 

VAN NUYS. Chemical Analysis of Healthy and Diseased 
Urine, Qualitative and Quantitative. 39 Illustrations. $1.00 

VENEREAL DISEASES. 

COOPER. Syphilis. 2d Edition, Enlarged and Illustrated with 

20 full-page Plates. $5.00 

GOWERS. Syphilis and the Nervous System. 1.00 

VETERINARY. 

ARMATAGE. The Veterinarian's Pocket Remembrancer. 
Being Concise Directions for the Treatment of Urgent or Rare Cases, 
Embracing Semeiology, Diagnosis, Prognosis, Surgery, Treatment, 
etc. 2d Edition. Boards, $1. 00 

BALLOU. Veterinary Anatomy and Physiology. 29 Graphic 
Illustrations. .80; Interleaved, #1.25 

TUSON. Veterinary Pharmacopoeia. Including the Outlines of 
Materia Medica and Therapeutics. 5th Edition. $2.25 



WOMEN, DISEASES OF. 

BYFORD (H. T.). Manual of Gynecology. Second Edition, 
Revised and Enlarged by 100 pages. With 341 Illustrations, many 
of which are from original drawings. $3 00 

BYFORD (W. H.). Diseases of Women. 4th Edition. 306 
Illustrations. Cloth, $2.00 

DUHRSSEN. A Manual of Gynecological Practice. 105 
Illustrations. $ I -5° 

LEWERS. Diseases of Women. 146 Illus. 5th Ed. $2.50 

WELLS. Compend of Gynecology. Illustrated. 

.80; Interleaved, $1.25 

FULLERTON. Nursing in Abdominal Surgery and Diseases 
of Women 2d Edition. 70 Illustrations. ii.50 



22 SUBJECT CATALOGUE. 

COMPENDS. 



From The Southern Clinic. 

" We know of no series of books issued by any house that so fully 
meets our approval as these ? Quiz-Compends?. They are well ar- 
ranged, full, and concise, and are really the best line of text-books that 
could be found for either student or practitioner." 



BLAKISTON'S ? QUIZ-COMPENDS? 

The Best Series of Manuals for the Use of Students. 
Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. 

4®~ These Compends are based on the most popular text-books 
and the lectures of prominent professors, and are kept constantly re- 
vised, so that they may thoroughly represent the present state of the 
subjects upon which they treat. 

4Sf The authors have had large experience as Quiz-Masters and 
attaches of colleges, and are well acquainted with the wants of students. 

4£g* They are arranged in the most approved form, thorough and 
concise, containing over 6oo fine illustrations, inserted wherever they 
could be used to advantage. 

>9®* Can be used by students of any college. 

>8S~ They contain information nowhere else collected in such a 
condensed, practical shape. Illustrated Circular free. 

No. I. POTTER. HUMAN ANATOMY. Sixth Revised and 

Enlarged Edition. Including Visceral Anatomy. Can be used 
with either Morris's or Gray's Anatomy. 117 Illustrations and 16 
Lithographic Plates of Nerves and Arteries, with Explanatory 
Tables, etc. By Samuel O. L. Potter, m.d., Professor of the 
Practice of Medicine, Cooper Medical College, San Francisco ; late 
A. A. Surgeon, U. S. Army. 

No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Sixth 
Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., 
Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot 
Clinical Medicine, Jefferson Medical College, Phila. 

No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. 
Sixth Edition, Revised and Improved. Same author as No. 2. 

No. 4. BRUBAKER. PHYSIOLOGY. Ninth Edition, with 
new Illustrations and a table of Physiological Constants. Enlarged 
and Revised. By A. P. Brubaker, m.d., Professor of Physiology 
and General Pathology in the Pennsylvania College of Dental 
Surgery ; Adjunct Professor of Physiology, Jefferson Medical 
College, Philadelphia, etc. 

No. 5. LANDIS. OBSTETRICS. Sixth Edition. By Henry G. 
Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., 
Instructor of Obstetrics, Jefferson Medical College, Philadelphia. 
Enlarged. 47 Illustrations. 

No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, 
AND PRESCRIPTION WRITING. Sixth Revised Edition 
(U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of 
Practice, Cooper Medical College, San Francisco ; late A. A. Sur- 
eeon. U S. Army. 



MEDIGAL BOOKS. 23 



PQUIZ-COMPENDS ?— Continued. 

No. 7. WELLS. GYNECOLOGY. By Wm. H. Wells, m.d., 
Instructor of Obstetrics, Jeffersorj College, Philadelphia. 150 Illus- 
trations. 

No. 8. GOULD AND PYLE. DISEASES OF THE EYE 
AND REFRACTION. A New Book. Including Treatment 
and Surgery, and a Section on Local Therapeutics. By George 
M. Gould, m.d., and W. L. Pyle, m.d. With Formulae, Glossary, 
Tables, and m Illustrations, several of which are Colored. 

No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- 
ing. Fifth Edition, Enlarged and Improved. By Orville 
Horwitz, b. s-, m.d., Clinical Professor of Genito-Urinary Surgery 
and Venereal Diseases in Jefferson Medical College ; Surgeon to 
Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. 

No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth 

Edition. Including Urinalysis, Animal Chemistry, Chemistry of 
Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, 
m.d., Professor of Chemistry in Pennsylvania College of Dental 
Surgery and in the Woman's Medical College, Philadelphia. 

No. 11. STEWART. PHARMACY. Fifth Edition. Based upon 
Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, 
m.d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- 
delphia College of Pharmacy ; Lecturer at Jefferson Medical 
College. Carefully revised in accordance with the new U. S. P. 

No. 12. BALLOU. VETERINARY ANATOMY AND PHY- 
SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor 
of Equine Anatomy at New York College of Veterinary Surgeons ; 
Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. 

No. 13. WARREN. DENTAL PATHOLOGY AND DEN- 
TAL MEDICINE. Third Edition, Illustrated. Containing 
a Section on Emergencies. By Geo. W. Warren, d.d.s., Chiet 
ot Clinical Staff, Pennsylvania College of Dental Surgery. 

No. 14. HATFIELD. DISEASES OF CHILDREN. Second 
Edition. Colored Plate. By Marcus P. Hatfield, Profes- 
sor of Diseases of Children, Chicago Medical College. 

No. 15. HALL. GENERAL PATHOLOGY AND MORBID 
ANATOMY. 91 Illustrations. By H. Newberry Hall, ph.g., 
m.d., late Professor of Pathology, Chicago Post-Graduate Medi- 
cal School. Second Edition. 

No. 16. DISEASES OF THE SKIN. By Jay T. Schamberg, 
m.d., Instructor in Skin Diseases, Philadelphia Polyclinic. With 
99 handsome Illustrations. 

Price, each, Cloth, .80. Interleaved, for taking Notes, $1.25. 

In preparing, revising, and improving Blakiston's ? Quiz-Com- 
pends ? the particular wants of the student have always been kept in 
mind. 

Careful attention has been given to the construction of each sentence, 
and while the books will be found to contain an immense amount of 
knowledge in small space, they will likewise be found easy reading ; 
there is no stilted repetition of words ; the style is clear, lucid, and dis- 
tinct. The arrangement of subjects is systematic and thorough ; there 
Is a reason for every word. They contain over 600 illustrations. 



/ 



Morris' 
Anatomy^* 






Second Edition, 
Revised and Enlarged. 

790 Illustrations, of which many 
are in Colors. 

Royal Octavo. f Cloth, $6.00; Sheep, $7.00; 
Half Russia, $8.00. 



From The Medical Record, New York. 

'• The reproach that the English language can boast of no 
treatise on anatomy deserving to be ranked with the masterly 
works of Henle, Luschka, Hyrtl, and others, is fast losing 
its force. During the past few years several works of great 
merit have appeared, and among these Morris's "Anatomy" 
seems destined to take first place in disputing the palm in 
anatomical fields with the German classics. The nomencla- 
ture, arrangement, and entire general character resemble 
strongly those of the above-mentioned handbooks, while in 
the beauty and profuseness of its illustrations it surpasses 
them. . . . The ever-growing popularity of the book 
with teachers and students is an index of its value, and it 
may safely be recommended to all interested." 

*** Handsome Descriptive Circular, with 
Sample Pages and Colored Illustrations, 
will be sent free upon application. 






